In any health practitioner’s career, there are some clients who are problematic. As clinicians, we try to screen for any obvious mismatches between the services we offer and the services a client wants at the beginning of the therapeutic relationship.
But some clients only become problematic after that practitioner-client relationship is established. These clients can be hard to move out of your practice—and at the same time can create a great deal of stress within it. Here we’ll address the ethical, emotional, and logistical components of what is, for many practitioners, an extremely difficult question: How do you fire a client?
What to Consider Before You Fire a Client
It’s almost always acceptable to fire a client. There may be exceptions to this depending on your particular code of ethics and on applicable laws where you are. Exceptions may also include situations when the client is in a crisis or emergency, or when there is no alternative service provider available. Most importantly, neither one of those situations is the client’s call to make—that decision begins and ends with you. If you’re having a hard time deciding whether it’s time to stop working with a particular client, here are some factors to consider.
The Ethical Questions
Some clients who don’t want to be referred out might begin to present themselves as constantly “in crisis” in hopes of keeping you involved. But just because someone says that they’re in a crisis doesn’t mean that they actually are. Assess their actual levels of symptoms and functioning, and make your decision to refer your client out or not based on those facts.
Other clients might refuse every referral you offer, finding problems with each of them. But when it comes to the non-abandonment clauses seen in many professional codes of ethics, the clinician’s responsibility is typically to simply offer referrals. The client isn’t obligated to take them. And as long as any crisis needs (as judged by the clinician) are reasonably met, the clinician has no additional obligation to a client who, for whatever reason, isn’t a good fit.
A client can’t be fired (or to put it more gently, referred out) because of their religion, ethnicity, gender, sexual orientation, or other protected factors. But here are some common reasons why clinicians terminate relationships with clients—even when the client would be willing to continue.
The clinician is changing their work schedule or location.
The clinician and the client don’t agree on the goals or methods of treatment.
The clinician and the client have a conflict in personality or values that’s undermining the effectiveness of the treatment.
The client isn’t making expected gains, and the clinician doesn’t believe that they will. Notably, in this situation many clinicians are actually ethically obligated not to continue treatment.
The client is experiencing barriers to care, such as transportation or child care needs, that are preventing them from receiving services and may be better alleviated with a different provider.
The client needs a higher level of care than what the clinician can provide.
The client is not attending scheduled services on a consistent enough basis to see improvement in symptoms.
The client’s symptoms or goals are not a good fit for the clinician’s practice.
In mental health care, many ethics codes also make explicit that clients can be referred out on the basis of inability to pay for the clinician’s services. In such situations, the clinician should include information about this possibility in their initial informed consent documentation.
The Emotional Impact
It’s common for clinicians to feel guilty about even having the desire to remove an active and willing client from their caseload. After all, the client sought help, which in itself is often a difficult thing to do. The client has also invested time and money into the work with their therapist so far. Quite often, the client didn’t do anything wrong, and in a private-practice setting, any lost client represents lost income. For these reasons, it’s not uncommon for clinicians to groan about—but still keep—mismatched clients on their caseloads.
In the moment, referring out a client who is a poor fit can feel stressful, or even morally wrong. But in the long term, you’re likely to be a happier and more effective clinician as a result of doing so. In my own experience, I’ve found that the majority of my professional stress came down to just a few high-stress cases.
Over time, I was able to weed out existing bad-fit clients and get better at screening at the beginning of therapy for those things that tended to become problems later. Once I could do that, I found that even a heavy caseload didn’t leave me exhausted or burned out the way that a moderate caseload with a couple of difficult clients could.
More importantly, it’s better for clients to be served by clinicians who are the right fit for them, in as many ways as possible. If your practice isn’t the right fit for them, referring them to a better fit is quite likely one of the best things you can do to maximize their chances of getting effective treatment.
The Logistical Side
Assuming you’re able to work through the ethical and emotional challenges to land at the decision that you’d like to fire a client, what do you do then?
First, it can be helpful to consult with a supervisor or trusted colleague. This can help you clarify the rationale for your decision in a way that you can clearly document. While complaints about abandonment are rare, if you have any concern at all about the potential for such a complaint, good documentation of the “why” behind your decision—and the steps you took to ensure continuity of care—can provide a great deal of relief down the line.
Then when it’s appropriate, discuss your decision with your client. Of course, there are times when such discussion isn’t appropriate or particularly helpful. But often, clients will appreciate clarity around such a decision. They may not like it, but if they can at least understand your explanation and clarity around the decision, it will help them not feel as though they’ve been strung along or did something wrong.
When you have this conversation, it’s important to be unambiguous about what is happening and why. If you’re a mental health clinician and you’re used to using tentative phrasing like “I wonder whether,” “I’m not sure about,” or “Have you considered,” this conversation is the time to take all such phrases out of your vocabulary.
At best, this language could be confusing to your client. They might start to think that you’re asking them to justify why they should continue treatment, or explain why you should keep working with them. That quickly becomes a very uncomfortable argument. But at worst, tentative phrasing here comes across as unprofessional. You’ve made your decision. Own it.
If you’re feeling nervous about having this conversation, it might be helpful to prepare yourself some kind of a script. You can use something like, “It’s become clear to me that my practice isn’t the best fit for you. Here’s why. [Explain your reasoning.] Now here’s what happens next. [Explain how you will help in their process of starting treatment with another provider.]”
If such a conversation isn’t possible or advisable, you can give the client that same information via a letter or an email, depending on how they’ve given permission to be contacted. If you’re sending this communication in writing, include the steps the client should take to allow you to transfer records to their new provider, and what they should do in the meantime if they believe that they are going into crisis. If you’re working on terminating treatment with a particularly high-risk client, you may first want to consult with your professional liability insurer to see whether they have any additional recommendations.
At the end of the day, you’re the best judge of your own expertise. If you feel that you and your client aren’t a good fit for each other, trust your professional judgement. Even if the interaction is uncomfortable in the moment, you and your clients will both be better off in the long run.
Disclaimer: This article is for educational purposes only and is not intended to be nor should it be considered legal or ethical advice. Every situation is different and requires context-specific consideration. If you have questions about your specific situation, contact your professional association, professional liability insurance carrier, or qualified attorney.
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