Terminating Ethically When Client Can't Pay--But is In Crisis

[foreverbull]

This would be a great ethics vignette to discuss with students:

Situation: you've only met with a client a few times but they are now in crisis. The person needs regular, weekly therapy longterm (and crisis services as needed), but you just found out that they can't afford your services anymore (not even one more session, although they need it).

What is the ethical way to terminate/refer out so that it isn't considered client abandonment?
Psychologists aren't obligated to offer free services, however, termination ethics is a gray area when a client can't pay but is high acuity and would have a lapse of services between therapists.

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[Psych_hopeful]

I think how this goes (at least from my Step 3 knowledge) is that it is unethical to discontinue care involuntarily once you have accepted a patient. If this is true for this situation, I would just adjust pricing accordingly. =/

This is probably the wrong answer, but maybe what I would do.

 

[deleted480308]

It is not unethical to discontinue care for nonpayment, you really should have that "firing" process in your new patient paperwork

 

[WisNeuro]

It is not unethical to discontinue care for nonpayment, you really should have that "firing" process in your new patient paperwork

Yes it is, if the patient is in crisis. Our ethical guidelines trump whatever personal belief system a practitioner chooses to have. Additionally, most of the state boards will also have statutes related to this.

OP, you can terminate, but you will have to make sure some kind of appropriate follow-up is made. Look into any community resources may be available, such as an intensive PHP or the latter. If you have social work resources available, refer there.

 

[deleted480308]

Yes it is, if the patient is in crisis. Our ethical guidelines trump whatever personal belief system a practitioner chooses to have. Additionally, most of the state boards will also have statutes related to this.

OP, you can terminate, but you will have to make sure some kind of appropriate follow-up is made. Look into any community resources may be available, such as an intensive PHP or the latter. If you have social work resources available, refer there.

I'd be interested in a citation that says a patient in psychiatric crisis can demand indefinite treatment without payment....

 

[MCParent]

I'd be interested in a citation that says a patient in psychiatric crisis can demand indefinite treatment without payment....

It's in most (all?) state rules.
If someone is in constant crisis than traditional individual psychotherapy is not the best treatment for them and they need inpatient. It's not unethical to tell a patient they are beyond your ability to ethically treat them and refer them out, even if they don't go, after you appropriately assess.
It says you can't require payment for emergency services. Doesn't say you can't bill them for it after.

 

[deleted480308]

It's in most (all?) state rules.
If someone is in constant crisis than traditional individual psychotherapy is not the best treatment for them and they need inpatient. It's not unethical to tell a patient they are beyond your ability to ethically treat them and refer them out, even if they don't go, after you appropriately assess.
It says you can't require payment for emergency services. Doesn't say you can't bill them for it after.

But you're pushing into emtala there.....an outpatient private clinic can require payment and begin a discharge process without it, if the patient is in an emergency state they can go the ED

 

[Mad Jack]

I'd be interested in a citation that says a patient in psychiatric crisis can demand indefinite treatment without payment....

Psychiatric care is a bit different than most fields, and has different rules in regard to discharging patients from your practice oftentimes, due to the special relationship between a mental health professional and their client. Being abandoned during crisis by someone you have developed a therapeutic relationship with can be a precipitant of suicide, self-harm, or the harm of others, and thus those in mental health have a greater responsibility than someone merely handing out blood pressure meds or the like in regard to their patients. Telling a patient, "can't pay, not my problem" when they are in crisis as a psychiatrist and them subsequently killing themselves would likely cost you your license.

 

[deleted480308]

Psychiatric care is a bit different than most fields, and has different rules in regard to discharging patients from your practice oftentimes, due to the special relationship between a mental health professional and their client. Being abandoned during crisis by someone you have developed a therapeutic relationship with can be a precipitant of suicide, self-harm, or the harm of others, and thus those in mental health have a greater responsibility than someone merely handing out blood pressure meds or the like in regard to their patients. Telling a patient, "can't pay, not my problem" when they are in crisis as a psychiatrist and them subsequently killing themselves would likely cost you your license.

I'm ok with learning something new here (although, I'd call that more of a professional licensing requirement than ethics)....can someone link a citation?

 

[Mad Jack]

I'm ok with learning something new here (although, I'd call that more of a professional licensing requirement than ethics)....can someone link a citation?

It's a standard of care thing, it isn't a part of state law, it's related to the standards of practice of the field. Here's a primer on just how dicey things can get:

Psychiatric Abandonment: Pitfalls and Prevention | Psychiatric Times

And this isn't to say you can't terminate. You can, you just have to give 30 days notice and help them find a new provider (or even more notice if they're in a rural area- in fact, you might end up with some patients that are virtually impossible to discharge if you're rural enough).

 

[deleted480308]

It's a standard of care thing, it isn't a part of state law, it's related to the standards of practice of the field. Here's a primer on just how dicey things can get:

Psychiatric Abandonment: Pitfalls and Prevention | Psychiatric Times

And this isn't to say you can't terminate. You can, you just have to give 30 days notice and help them find a new provider (or even more notice if they're in a rural area- in fact, you might end up with some patients that are virtually impossible to discharge if you're rural enough).

From that: "
Patients must pay their bills. It would be detrimental to the patient's acceptance of responsibility, as well as an indication of something unusual about the therapist, if bills were allowed to go unpaid. No therapist should suddenly end a relationship because of an unpaid or disputed bill. It would be legitimate to do so, however, after reasonable efforts to work things out have failed and the patient has had suitable warning.

There are, however, circumstances that may hamper a cooperative patient's ability to pay, such as problems with insurance, job loss or sudden illness, and the question of abandonment can arise if the patient stops therapy due to lack of funds. While no psychiatrist is required to work for free for extended periods of time, some largesse is expected by the court (especially juries) when patients are in crisis.

Of course, psychiatrists will have different opinions about what constitutes lack of funds. Does a patient's refusal to work extra hours in order to pay for needed treatment constitute a need for the psychiatrist to provide transitional services? These types of questions are tricky and require consultation with colleagues and the lawyers or legal experts of malpractice insurance companies. Their opinions should be recorded and followed, as they will apply the same standard of care as the courts."


.................it seems to basically agree that you can fire people for non-payment, it just has to be a well documented and careful process. I don't think that should be the case, but legal realities are what they are I guess

 

[erg923]

Situation: you've only met with a client a few times but they are now in crisis. The person needs regular, weekly therapy longterm (and crisis services as needed)

By definition, crisis is short term. See the crisis. Refer for "long-term" if they aren't able to pay (and you are in PP).

A crisis session should be about assessment of safety and triage to a level of care that you may not be able to provide.

 

[WisNeuro]

No one is advocating indefinite treatment. They are advocating stabilization, or appropriate referrals for stabilization for crisis. But you can't just discontinue treatment at will, even for non-payment in crisis situations. Luckily, Ayn Rand doesn't write our ethical guidelines or state statutes. Adults do.

 

[foreverbull]

Taking into account the variety of responses, the general consensus seems to be that a crisis/termination session (whether or not the client can pay), providing referrals to both low-cost therapists (for long term care) and intensive services (hospital or partial hospital for short-term stabilization), and of course safety planning/assessment in that session would be an appropriate course of action?

 

[PsyDr]

in addition to what others have said: Call the APA trust's legal helpline, ask them, and then document it. Then call the APA ethics office helpline and repeat.

 

[temppsych123]

Taking into account the variety of responses, the general consensus seems to be that a crisis/termination session (whether or not the client can pay), providing referrals to both low-cost therapists (for long term care) and intensive services (hospital or partial hospital for short-term stabilization), and of course safety planning/assessment in that session would be an appropriate course of action?

Also, consider calling your state licensing/ethics board for their view, consulting with colleagues about the practice, and DOCUMENT all consultation you've done/received that informed your decision.

 

[foreverbull]

Will do. Thanks for the suggestions, everyone!

 

[foreverbull]

Update for those interested: an ethics consultant in my state psych association confirmed that a final session with referrals was an appropriate action in this situation. No further follow-up would be needed beyond the session as long as client is not an imminent/immediate danger to self/others in session.

 

[Psych_hopeful]

Update for those interested: an ethics consultant in my state psych association confirmed that a final session with referrals was an appropriate action in this situation. No further follow-up would be needed beyond the session as long as client is not an imminent/immediate danger to self/others in session.

Ah. That's interesting. 🙂

Ya this was a good case to learn from.