I just don’t think this is working.” Said my client’s mother, mid-session (a difficult session) and then she started to cry.

I realized at that point that I had to change something, for her. While I knew that “it” wasn’t working for a large number of reasons, I was torn. My client is yelling and hitting, repeatedly, and not engaging in sessions. Engaging is hard. It’s why he’s in therapy. My client also shows “bad” behaviors because it’s become his learned way of operating. It’s why he needs more and different therapy than I alone can provide, and why I’m supporting them through to the other side of this pandemic and to help them connect with additional professional supports. Stopping now means giving in to his negative behaviors and poor coping strategies which brought them to me in the first place. But does it? I realize that stopping now also means meeting this family where they are in their journey and respecting a mother’s desire for what she wants or needs her family to look like right now. And so I said,

 “O.k. Let’s stop.”

This mother felt self-judgement. She told me that outright. I am guessing she felt worried about my judgement and I know she feels failure, either in herself or the process. My answer to her when she asked, “Is that o.k.?” was a confident,

“Yes. There is no judgement, and no wrong decision when it comes to knowing one’s limits and respecting them, and when you choose to do your very best, even if it means that therapy doesn’t fit with your family right now.”

Most people seeking occupational therapy (OT) services, don’t think about giving up on therapy. They are usually more concerned with knowing when they need to seek services and with learning about what therapy entails. Parents don’t want to miss something when it comes to helping or supporting their children. Parents often find starting therapy an overwhelming process or they may already be in an overwhelmed state. In my private practice I also see parents feel a giant sense of relief after starting therapy because someone finally “get’s them” and their child. Additionally, who wants to think about NOT doing what has just brought relief? For all these reasons, most parents don’t think about stopping services, at least for awhile.

Why Do We Need Discharge Criteria?

Even though discharge is not always on a parent’s or a therapist’s radar, I think it’s important to establish the discharge criteria and have realistic expectations right from the start. Having desired outcomes established early on helps:

  • parents settle into the process, which also helps children settle in
  • guide the treatment plan and keeps sessions on track, so the therapist knows what to prioritize each session and how to best support a child or family at any given time, over time
  • prioritize resources including time, finances, and personal energy (for parent AND therapist)
  • establishes boundaries and operating procedures which can support effective communication throughout therapy

All of the above items help to improve overall outcomes of the therapy process.

How Do We Decide Discharge? 

But how do we know when enough is enough? Short answer?…We don’t always know. But there are some criteria, I’ve put together over the years that help me decide when it’s time to stop or to recommend discharge.

  1. When a parent wonders out loud to me how much longer services will last. This is a clue to me that something has changed. It’s my cue to start asking more questions and to check-in so we can evaluate progress and desired outcomes. Re-evaluation when I get this question, usually helps all of us to re-establish new criteria for staying in therapy or shows us that outcomes to date are satisfactory to the family for right now.
  2. Progress on identified goals has ceased over a reasonable amount of time and the family does not identify new or different goals that are currently relevant. If treatment has been tried for a reasonable duration of time based on practice guidelines and no progress is evident, it is a reasonable response to stop therapy or take a different course of action. If no other goals are important to the family, it is client-centered practice to recommend discontinuing services. Education about what to watch for in regards to regression, preventing regression, and future indicators of need for returning to therapy may be needed.
  3. I’ve exhausted my best clinical efforts to elicit more progress using various strategies that usually work for clients with similar challenges. This often comes up with children who have co-occurring conditions or have medically complex needs. This also comes up when families are going through life transitions and/or the child is in a new developmental stage. This is often my clue to think about reason 4, below.
  4. New clinical needs arise for which another discipline is better suited is a reason for me to “pause” or discontinue because as much as I like to think I know a lot, I am not always the discipline or professional that my clients need. Knowing my scope of practice and sticking to it, is critical for helping our clients.  This may mean losing a client, but we have to be willing to provide what clients need most, even when that means a referral or a pause in OT services.
  5. Resources have decreased and have made therapy unsustainable and a lower level of service (lower frequency or shorter duration of sessions) are not likely to yield the desired outcomes. Resources such as time, finances, and personal energy play into whether therapy works and how long it lasts.  We have to help families make the best of what they have for the highest amount of gain we can get within those constraints.
  6. I and my client(s) disagree on the “terms” of therapy. Thankfully, this doesn’t happen often, but it does arise.  When this scenario presents itself, usually a direct conversation sheds light on a deeper reason for the disagreement (see all the reasons above) but there are also times when a client disagrees with how I am doing things.  When this happens it’s allowed and I remind myself, that I can’t help everyone and that sometimes we will see things differently. I reiterate, therapy is a personal relationship, and there are times when disagreement about how to support someone means they will see someone else or may choose not to participate in therapy.  It is always a client’s choice.

Making the decision to stop treating a child can be one of the most challenging decisions we face as a therapist.  We don’t go into this field to “stop helping.” But having clear criteria for when it’s time to stop, can actually be a way of helping.  Stopping at the right time can mean a client is satisfied, it can mean they feel heard or validated, and it might mean they are getting the help they need. We don’t always have to be the one providing the help, but we do need to be sure we are helpful to clients at each stage in their OT journey.

If you are a parent wondering about your child’s treatment plan or next steps, or if you are a therapist who wants to brainstorm whether it’s time to discharge a particular client, don’t hesitate to reach out to me directly. Input from an objective but trained person can be helpful.  I am here to help. – Kelly

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