… One aspect of termination and referral that I have not previously written about involves the issue of follow-through after a referral is made and communicated to the patient. Referrals are usually made after the therapist or counselor decides to terminate with the patient, which may occur for a variety of reasons. Perhaps the practitioner has determined that the patient is not sufficiently benefiting from the treatment and would be better served by another practitioner – whether of the same licensure or otherwise. Therapists or counselors may terminate because the patient is no longer able to pay the previously agreed upon fee or because a conflict may have arisen requiring, in the judgment of the practitioner, a termination. Additionally, a termination may occur because the practitioner becomes ill or is otherwise incapacitated.  It is of course possible that the patient or client will unilaterally terminate treatment for one or more reasons.

Whatever the reason for termination may be, the therapist or counselor is likely to be under the ethical and/or legal duty to refer the patient or client elsewhere – whether to an individual licensed practitioner, or to a governmental agency, such as a county mental health facility, or to a nonprofit organization providing counseling or psychotherapy services. Once the referral is given and the termination occurs, there would seem to be nothing further for the therapist or counselor to do. In fact, many practitioners believe that they owe no further duty to the patient. Therapists and counselors should be sure to carefully and fully document the entire termination process. Doing so could prove critical. 

Suppose that the patient is severely depressed and that the referring professional is concerned about self-harm to the patient. Assume further that a referral was made to a psychiatrist because the therapist or counselor determined that the patient was not sufficiently benefiting from the treatment and that the problem was worsening. Would it be sufficient for the referring practitioner to have no further contact with the patient after making the referral in the last session? Might a court determine that the therapist in this case was under a duty to make a reasonable attempt to follow-through with the patient (or the psychiatrist) to see whether the new relationship has begun? Might a court determine that the termination was not handled appropriately and that the therapist or counselor has liability for the harm that came to the patient after a botched termination and referral?

These questions are not easy to answer, and much depends (as always!) on the particular facts and circumstances, and the law in the state in which such a situation occurs. The issues of termination and referral may be covered, to some extent, in state statute or regulation. More likely, common law principles involving the issues of “duty” and “negligence” will be applied to particular cases. Generally, the duty of a therapist or counselor begins when a contract for professional services is entered into – whether in writing or orally. Likewise, I believe that the duty to the patient should end concurrently with the termination of the therapeutic relationship. This of course assumes that the termination is made in a clinically appropriate manner. It is my view that a proper termination process requires the therapist or counselor to carefully consider whether a referral is necessary or appropriate, and if so, how will the actual referral be handled.

In some cases, such as the one described above, it might be appropriate for the therapist to call or otherwise contact the terminated patient, or ask the patient to communicate with the therapist, for the purpose of assuring that the patient is following through on needed treatment. In some cases, the therapist or counselor may be compelled to take other action (e.g., arrange for an involuntary commitment) when it is determined that the patient is not following through with the referral. Perhaps the post-referral contact reveals something to the practitioner that indicates a worsening of the patient’s mental or emotional condition. Unless state law or regulation dictates or specifies when the duty (to provide competent care) to the patient ends, the therapist or counselor may not be able to avoid taking some form of action after a referral is made.