Back in grad school, I liked those vignettes where the clinician actually gets to terminate with clients and engages in the process of a healthy goodbye. Aaah! What a gift to co-create a corrective experience of closure when a client is graduating from therapy, or when you’re doing a warm handoff to the next intern who will take over your cases because you’re graduating.
And then, you end up in community mental health or private practice wrangling real-life while trying to make a living. You see fewer of those actual terminations, and more of situations that leave you scratching your head with confusion, or worrying that something terrible might have befallen your client. And either which way, you have this sense that there are loose ends that you may not be able to tie up.
So speaking of loose ends, how many open cases do you have that should have been closed out a while ago?
Remember that client who came for three sessions a couple of months ago, and then never returned?
Or how about that client who started a new job and needed a different time-slot, but then became “too busy” to return to therapy?
Or the client who said they would resume therapy after the summer, and then didn’t call you back?
Or how about the couple who came once (maybe twice) and then no-showed and did not return your call?
I’ll come clean – I definitely find myself challenged by situations like these. And sometimes I feel a bit sheepish wondering how many times to reach out to the client. Or I get hard on myself about not “being on top of it!”
Let’s cut ourselves some slack here – we’re doing the best we can, and our jobs are not easy. It is almost easier to handle the ongoing crises situations that keep popping up, than to do the maintenance type tasks of updating treatment plans, auditing files and closing out cases.
I wish I had a magic solution to all of it, but one thing I can tell you, is that sometimes, a thoughtful termination phone call is the best way to wrap up a case. This way, you can document the final outreach to the client, and close the client file. For now, at any rate!
Oddly enough, this termination phone call has sometimes resulted in long absent clients deciding that they are now ready to return to therapy. So who knows, this call might just be what it takes to move therapy to the next level.
When I have not seen a client in the recent period, and it seems that they do not plan to return to therapy at this time, I usually go through a simple process and create a mental map, prior to initiating a phone call. While this is not clinical supervision, consultation, legal or ethical advice, here are some thoughts about closure, in the hope that they might be useful to you as well.
Frequency: This topic is fraught because no two situations are alike. Some clinicians will only leave one message for a client who no-showed, while others will leave as many as three or four. I tend to lean towards two phone calls, although there have certainly been times when I have reached out a third time, if the situation called for it.
Typically, if I do not get the person live, and need to leave a voicemail during the first call, I ask for a callback from the client. However, I also let them know that if I don’t hear from them within a week, I will attempt to reach them one last time.
Sometimes, this is the encouragement that some clients need, and I will get a call back wanting to schedule an appointment.
Duration: Ideally, it would be best to review your files at least once a quarter so that you can either continue the clinical work or close out the case. However, you need to determine the ideal timeframe that works for you, your agency, your supervisor etc.
Logistics: While this blog is mostly focused on handling this situation by phone, this may not be ideal for your client population. For example, if you work with survivors of domestic violence, it may not be safe for them to receive a phone call, email or postal mail from you. Therefore, it is up to you to determine how best to proceed in each, unique situation.
The suggestions that follow are ones that I have used in phone calls, and occasionally in writing. Don’t forget to read the disclaimer at the bottom!*
Mindset: I like to do a review of my case notes, so that I am activating the therapeutic container. This phone call, even if brief, is a continuation of the therapeutic alliance, and I want to be in the right frame of mind, before I reach out to the client. I have to be prepared that either the client will answer the phone, or that I might be leaving a voicemail, and I like to be ready for either scenario.
For me, the most important part of preparing for this phone call, is recognizing the mutuality and reciprocity of the therapeutic alliance. I believe that if I can embody how I have been made vicariously resilient by this client, then I can convey a positive, empowering message in this phone call.
Positive Reinforcement: Like you, I believe in a strengths-focused approach that positively reinforces clients. Therefore, I make every effort to recognize the client’s efforts in therapy. And having completed a quick file-review prior to picking up the phone, I am usually well prepared to remind the client of their progress in therapy.
I make sure to thank them for their hard work, because as therapists, it is all too easy to forget exactly how hard it is to be a client!
Acknowledgment: I like to thank the client for the opportunity to work with them. I like to share what I most appreciated about working with this person. I try to make it unique & specific. This allows them to continue to benefit from the therapeutic alliance, and this acknowledgment can be a corrective experience for many clients who have felt unappreciated or undervalued in their family of origin, romantic relationship or society.
Validation: I validate the client’s choice to not be in therapy at this time. Sometimes, I will include their stated reason for not being in therapy, such as “I know that life can get very busy at times, and I understand that this may not be the best time for us to continue our work.”
Reminders of Support: I find it helpful to remind clients of the support that is available to them, since this is a big part of what I focus on in therapy. I encourage clients to widen their reach to include a variety of different forms of support, as well as coping tools and mindfulness practices. I believe in reinforcing these tools during the termination call, and a couple of clients have commented on how helpful this was for them.
Closing or Continuing: My goal is to help the client experience a closure free of any shame or blame, so I try my best to be neutral about the possibility of closing the case or continuing. I let clients know that in order to handle the administrative aspects of therapy, I will be closing the file (as of today/next week/specific date). However, I always make sure to let clients know that closing the file in no way affects their ability to return to therapy, either now or in the future. I invite them to contact me, should they wish to continue at any time. I also offer them the option that I would be happy to refer them to a colleague, if that would be helpful for them at any time.
Gratitude: I generally conclude the message or the call, by thanking the client, once again, for the opportunity to be a part of their journey. I wish them well and invite them to contact me, if I can be of assistance, now or in the future.
Contact Info: I wind up by leaving my contact information once again, should the client need it.
Document & Close File: Once I hang up the phone, I document the details of the call, or the voicemail and archive the file.
Although I’d prefer to have a face-to-face process with clients as they complete therapy, I am also aware of the constraints of reality, so this modified process is my workaround.
And the best part is that I feel some sense of closure as I complete this process, leave a thoughtful voicemail, document this message and archive the file.
So how do you handle termination after no-shows? I’d love to hear from you!
* I’m happy to share what has worked for me, and invite you to use it wisely, and with supervision/consultation as needed. Also see the disclaimer 🙂