Eye on Ethics

Terminating Services
By Frederic G. Reamer, PhD
Social Work Today
May/June 2006

Terrence stormed out of his house after another argument with his wife, Wanda. Wanda had threatened to file for divorce if Terrence did not get help with his explosive behavior and drinking problem. During the past two years the couple fought frequently; Terrence was often verbally abusive toward Wanda and occasionally hit her.

Terrence agreed to go to the local community mental health center for counseling. After completing the intake process, Terrence was referred to a clinical social worker, Marcia. Marcia and Terrence agreed to meet weekly for counseling; Terrence’s insurance company authorized 10 sessions.

At the end of the ninth counseling session, Terrence talked about how much he was benefiting from counseling and how, for the first time, he could talk about how he was affected by his abusive father. Terrence also began to address his alcohol problem and attend Alcoholics Anonymous meetings. Based on his progress, Marcia contacted Terrence’s insurance company and requested authorization for 10 additional sessions. The managed care company representative only authorized four additional sessions.

During their last session, Terrence began crying and talked about how depressed he was feeling, how distressed he was about issues in his marriage, and how much he wanted to continue counseling with Marcia. Unfortunately, Terrence’s insurance coverage had run out and he could not afford to pay for counseling out of pocket. Marcia understood that Terrence was feeling vulnerable, but she did not think her agency would permit her to continue counseling Terrence without payment.

Various circumstances can lead social workers to consider terminating services to clients. Social workers may leave their employment setting, retire, or become disabled. Or, social workers may decide to terminate services to a client whose insurance coverage runs out, who has a large unpaid balance, or who is noncompliant with treatment (for example, by missing appointments or ignoring program requirements or treatment expectations).

Avoiding Abandonment
Social workers must handle issues surrounding the termination of services very carefully to protect clients and minimize risk. Clients whose services are terminated unethically may not receive the services they need and, as a result, may pose a threat to themselves and others. In short, social workers must avoid abandoning clients.

Abandonment is a legal concept that refers to instances when a professional is not available to a client when needed. Once a social worker begins providing services to a client, he or she incurs a legal and ethical responsibility to continue that service or properly refer a client to an alternative service provider. Social workers are not, of course, obligated to serve every individual who requests assistance. They may not have room in their schedule for new clients or may lack the specialized expertise a particular client may need.

However, once a social worker begins service, he or she cannot terminate it abruptly. Social workers are obligated to conform to the profession’s ethical standards regarding termination of service and referral to other providers in the event the client is still in need. As the National Association of Social Workers Code of Ethics states, “Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary” (standard 1.16[b]).

In general, social workers who consider terminating services to clients should follow several guidelines to meet the following ethical obligations:

• Social workers in managed care settings should be particularly careful about the ways in which they terminate services. If clients’ insurance companies refuse to authorize services or an extension of services, social workers should be sure to advise clients of their right to appeal the decision and offer to assist the client with the appeal process. Otherwise, social workers may expose themselves to allegations that they abandoned their clients.

• When it is necessary to terminate services, provide clients with names, addresses, and telephone numbers of at least three appropriate referrals.

• When feasible, follow up with a client who has been terminated. If the client does not visit the referral, contact the client about the risks involved should her or she not follow through with the referral.

• Clients who will be terminated should be given as much advance notice as possible.

• When clients announce their decision to terminate prematurely, explain the risks involved and provide suggestions for alternative care. Include this information in a follow-up letter.

• Carefully document in the case record all decisions and actions related to termination of services.

• Provide clients with clear written instructions to follow and telephone numbers to use in the event of an emergency. Clients should be asked to sign a copy of the document, affirming that they received the instructions and that the instructions were explained to them.

• In cases involving discharge of a client from a residential facility, formulate a comprehensive discharge plan and notify important third parties of the client’s discharge when there is risk involved (discuss this with the client). In cases involving court-ordered clients, seek legal consultation and court approval before terminating services.

• Social workers leaving an employment setting (for example, to start a new job, move out of town, or retire) should inform clients of appropriate options for continuation of services and the benefits and risks of the options.

• Consult with colleagues and supervisors about decisions to terminate services. In some cases, addressing relevant issues can prevent termination. For example, social workers may be able to address a client’s reason for not paying an overdue balance and develop a workable payment plan. Social workers may be able to advocate on a client’s behalf with managed care organizations that have been reluctant to authorize additional clinical sessions. Social workers whose clients are noncompliant or not making reasonable progress may be able to modify their intervention approach.

In a perfect world, social workers would be able to provide clients with whatever services are necessary and for as long as necessary. Unfortunately, for diverse reasons ranging from lack of funding to client noncompliance, social workers sometimes need to consider terminating services. In such circumstances, social workers should carefully adhere to the profession’s ethical standards.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.