No (?) duty to see patient

• abandonment or acceptable practice? by Bob Madden, 2/16/99
  
  

Therapists do not generally have any duty to see patients they don't want to see; however, as you point out, once a clinician-patient relationship is established, the patient must not be abandoned. Abandonment usually consists of a clinician voluntarily either (1) not finding a substitute clinician for clinically necessary, acute, or emergency needs and/or (2) not providing appropriate advance notice. Although dealing with limit-testing and other primitive issues in borderline patients should be routine for therapists who work with them, "abandonment" in circumstances such as you describe is generally not a "legalistic" issue (though transition and termination are important processes in psychotherapy in general), provided the patient can take care of himself/herself. In psychotherapy, there would seem to be few "legal" abandonment cases, except for suicidal or crisis patients. Assuming the facts are as you describe, and that the clinician (a) saw no danger (or ameliorated any danger) to the patient in the termination and (b) gave adequate advance notice if feasible, the Board "consultant" is, in my view, in error if his/her main criticism is that the therapist should have known borderline patients act like that. Therapists are under no obligation to see patients they don't want to see, borderline or not, and can decline or terminate for just about any reason (including lack of payment or discomfort with the treatment issues,). When a patient threatens the therapist, all bets are off. Of course borderline and other primitive character styles are something one should work with _when feasible_, and I don't advocate terminating every time things get tough, but such patients have the ability to make treatment impossible, and I don't usually blame the therapist. In fact, a therapist who continues to see a patient while doubting her ability to treat adequately is breaching her duty to stay within her competence. Finally, patients who sabotage their own care by creating substantial fears or dangers should not, in my view, be rewarded with an "understanding" therapist. It's not good for either party. In such cases -- which are different from the fiduciary duty to a patient who is a danger to himself -- I vote to protect the clinician. ... That's pretty verbose. Other comments??

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