In her 2019 book titled Maybe You Should Talk to Someone, Dr. Lori Gottlieb stated that individuals commonly seek therapy during inflection points in their lives. Indeed, triggers for the development of psychological disorders often include life changes related to relationships, traumas, and losses (Riachi et al., 2022). However, it is also common practice for psychotherapists to continue providing psychological support long after these triggers occur. Today, courses of continuous psychotherapy in the United States vary widely, from the standardized 12-20 sessions for cognitive behavioral therapy (CBT) to years of talk therapy. Although evidence-based interventions such as CBT, dialectical behavior therapy (DBT), and others are considered the gold standard of treatment, a significant portion of psychotherapists continue to see patients for months to years following these so-called inflection points (David et al., 2018). Therapists who provide long-term therapy services may grapple with their role as interventionists, monitors of patient well-being, or a unique combination of the two. These providers may also wonder if providing long-term therapy is ethical in an era in which rates of mental illness continue to rise and provider capacity diminishes. Remaining aware of the ethical implications of engaging in long-term therapy is crucial to the goal of being both a holistic and effective treatment provider.

Long-term therapy is a difficult construct to define, as many providers view treatment courses as dynamic and dependent on patient progress. In contrast to long-term therapy, well-established behavioral and cognitive interventions such as CBT, DBT, and exposure and response prevention (ERP) propose standardized treatment plans which may be time-limited by design. Additionally, some historically long-term intervention styles, such as psychodynamic interventions, have been adapted to brief, contemporary models in recent years.  Psychologists trained to offer these modalities in their practice abide by the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as APA Ethics Code), which states that psychologists must work to provide care that is “based upon established scientific and professional knowledge of the discipline” (APA, 2017, Standard 2.04). To adhere to this principle, psychologists who choose to offer long-term therapy to their clients should routinely evaluate the efficacy of their practice.

Scheduled administration of outcome measures that assess the efficacy of their treatment is one way in which psychologists who provide long-term therapy may quantify patient improvement and, in turn, maintain adherence to the APA Ethics Code. Not only can these outcome measures (e.g., self-report symptom inventories, structured interviews) serve as empirical data to support clinician decision making, but a meta-analysis found that psychotherapists who administer outcome measures had significantly greater rates of improvement than those who did not (Tarescavage & Ben-Porath, 2014). The use of outcome measures may also help therapists abide by APA Standard 2.01 (Boundaries of Competence), which states that psychologists are obligated to recognize, and take appropriate action when, their competencies fall outside of the scope of interventions from which their patients may benefit (APA, 2017). Additionally, clinicians who offer services beyond a time-limited scope, should hold Principle A: Beneficence and Nonmaleficence at the forefront of their activities to ensure they continue to evaluate their personal ability to "benefit those with whom they work and take care to do no harm” (APA, 2017).

Unfortunately, decisions to interrupt or terminate treatment may trigger strong feelings from both providers and patients. Patients may interpret these conversations as a sign that they are unable to be helped, while providers who feel determined to support and improve patients’ well-being may experience feelings of guilt if their efforts are insufficient. One way in which psychologists can maintain rapport with patients and abide by ethical standards is to address the topic of treatment termination during the informed consent process. Informing patients during an intake session that their provider will routinely assess their progress during psychotherapy, especially in cases where an intervention is not clearly time-limited, is crucial to managing expectations around the process and ensuring the highest standard of care is available to the patient. Patients should be informed that treatment efficacy will be collaboratively evaluated in order to limit disruptions in rapport if psychologists deem interruption or termination of treatment is best practice. According to Standard 10.01 Informed Consent to Therapy, psychologists must inform patients “as early as is feasible” about the “nature and anticipated course of therapy” (APA, 2017). Establishing realistic expectations with patients about the plan for treatment, especially in the case of non-standardized or emerging treatment modalities, is essential for psychologists hoping to provide ethical care. Including patients in this decision-making process will likely aid in maintaining therapeutic alliance, a critical determinant of improvement in mental health (DeAngelis, 2019).

It is no surprise to practicing psychologists that national rates of mental illness continue to rise (Udupa et al., 2023). Additionally, providers are increasingly familiar with patient complaints about difficulty finding a psychotherapist. The imbalance between patients needing to access psychological care, particularly specialty care, and limited provider availability, may be a consideration when establishing a course of treatment. Knowing when other forms of care, or a termination of treatment, is appropriate is therefore crucial in providing ethical care. This is true not only from a patient well-being perspective, but also from an economical perspective. Improving outcomes and reducing costs, or a cost-benefit analysis,  may be one ethical consideration when providing long-term therapy, one which reflects the spirit of Principle D: Justice, which states: “Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists” (APA, 2017). Offering therapy that is both effective and approachable from an economical perspective is imperative. Continuing to see patients for the sole purpose of monitoring their well-being may result in periods of time when the cost of therapy outweighs the benefits. Both lack of provider availability and economical burden of long-term therapy may produce ethical dilemmas that providers who wish to offer long-term therapy might encounter. In light of this, providers should also remain attuned to the necessity and justification of clinical services.   

Patient-centered care and improvements in well-being are the foundation for all psychologists' goals. To achieve these goals while abiding by the APA Ethics Code, psychologists should assess the ethics of their practice in the context of provision of long-term therapy. Decisions about the empirical nature of this style and the role of cost-benefit analyses are essential for providers whose treatment philosophy and clinical focus supports treating their patients for extended periods of time. Establishing realistic expectations, evaluating efficacy of services provided, and using shared-decision making principles are also critical. Furthermore, referring to more appropriate forms of care if patient outcomes are insufficient is a vital, and ethical, decision in this process. Ultimately, providers who engage in ongoing, collaborative assessment of their patients’ progress toward their stated treatment goals will be well-positioned to recognize when a patient's therapeutic goals have been met or when other modalities are clinically indicated.

References

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code

David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in Psychiatry, 9, 1-3. https://doi.org/10.3389/fpsyt.2018.00004

DeAngelis, T. (2019, November 1). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10). https://www.apa.org/monitor/2019/11/ce-corner-relationships

Gottlieb, L. (2019). Maybe you should talk to someone: A therapist, her therapist, and our lives revealed. Harper.

Riachi, E., Holma, J., & Laitila, A. (2022). Psychotherapists’ views on triggering factors for psychological disorders. Discover Psychology, 2. https://doi.org/10.1007/s44202-022-00058-y

Tarescavage, A. M., & Ben-Porath, Y. S. (2014). Psychotherapeutic outcomes measures: A critical review for practitioners. Journal of Clinical Psychology, 70(9), 808–830. https://doi.org/10.1002/jclp.22080

Udupa, N. S., Twenge, J. M., McAllister, C., & Joiner, T. E. (2023). Increases in poor mental health, mental distress, and depression symptoms among U.S. adults, 1993–2020. Journal of Mood and Anxiety Disorders, 2. https://doi.org/10.1016/j.xjmad.2023.100013