Ethics: Case Vignettes Simulations

Ethics Case Vignettes Simulations

Case One

An attorney refers many clients to you for psychological evaluations. A close friend of yours has retained this attorney, who refers your friend to you for a very important psychological evaluation.  The attorney tells your friend that you are the “best” and the “best” is needed in this case.  You are strongly encouraged by both the attorney and your friend to do the evaluation.

 

The recommendation made by the attorney may be based on my professional qualifications but it could provide a legal and ethical dilemma that could prove detrimental to the case under scrutiny. As a psychologist, one would expect the occasional consultation from a close friend or family member with the context of such conference being non-professional. However, any supply of counsel to individuals with prior close relationships should not be extended to continued therapy sessions or psychological evaluations of a specialized nature such as this.

The ethical clash emanates from the potential of transference and counter-transference which is in turn as a result of mutual emotional involvement of personal relationships such as that of close friends. In order to provide professional mental health help, the needs of the client have to be catered to in a bid to achieve psychological improvement within a predetermined timetable that ceases to be in effect once this goal is achieved. As a result, combining friendship with a professional relationship of any nature may lead to harmful effects to both parties due to disparities in expectations and trust in the psychological process. In fact, the APA’s ethics code clearly prohibits such professional commitments which have the potential to be harmful to either party as a result of “pre-existing relationships” (Corey, Corey & Callanan, 2003).

These ethical issues have the potential to be used against my credibility and that of the psychological evaluation of my close friend. Among the issues that may be raised include my ability to endorse a qualified decorum to deal with the intrusive and often uncomfortable process of psychological evaluation, considering the prior relationship that exists with the client. As a result, the emotional involvement with my friend will probably bring about the question of possible bias towards the client when making an assessment of the situation. This will in most cases be considered as a violation of professional trust as well as an abuse of my skills as a mental health professional.

To avoid further legal complications that would include an undefined region between privileged information obtained during the psychological evaluation and knowledge on issues pertaining to the prior relationship; I would opt not to take on the case of the close friend. My professional expertise may be considered biased and should therefore be directed at providing emotional support, information and suggestions on an emergency support basis if required. The most ethically practical and legally sound approach would therefore be directed at referring the case to an equally competent professional that has no prior emotional relationship to my friend.

 

Case Two

You have a client who has adjusted a very busy schedule in order to be able to attend therapy sessions. You cancel a session to attend a funeral for a family member.  The client becomes irate and demands to be told the reason why you cancelled.

 

Self-disclosure on the part of a psychologist should be controlled to as minimal a level as possible. The client’s inquiry, though valid, has the potential to lead to a violation of the personal boundary that exists between me and him, as well as influence a change of attitude on the part of the client. This ultimately transfers the focus of treatment from pertinent issues discussed during therapy towards more private matters such as that of the funeral which may not have direct value to the client’s situation. At the same time, total disclosure on my part may lead to a form of transference where the client is inclined to identify, sympathize or even empathize with my recent loss, further derailing him from directing his attention to the initial goal of the therapy sessions.

Further ethical concerns stem from the fact that self-disclosure on my part will probably lead to the initiation of other personal discussions that will not only derail the therapy process but leave it biased towards issues that compromise my professionalism. This will result in additional emotional stress on the client who may have underlying issues that are related to the loss of loved ones or dealing with related forms of grief. Unless such a situation is controlled, it could have the potential to lead the therapy sessions to follow a more detrimental route for both parties involved.

When further considering the welfare of the client, it would not be professional for any psychologist to burden the client with personal information, especially since some clients do not have the emotional capability to handle such emotional boundary crossings. The provision of strict boundary limits in the client-therapist relationship enforces the client’s attitude to the entire process. Any breaches of such boundaries will not only affect issues of trust between me and the client, but will may also have the potential to affect self-esteem and individuation matters that are addressed in the process of therapy. These concerns usually arise as a result of the client looking up to the psychologist for their professionalism as well as for their provision of an avenue where the interests of the client are held at prime esteem.

Therefore, to efficiently handle the situation of the irate client, an apology for the absence is necessary especially considering the client’s efforts, but the same may not suffice. However, to avoid further social relationships that may have the potential of developing as a result of full disclosure, a slight and professional explanation would be essential. This would be encompassed in a reason such as being caught up on a ‘personal matter’ that was both ‘urgent and unavoidable’. This would clearly spell out the boundaries of social relationships that should exist between the client and I thus further avoiding any emotional dependencies outside the context of therapy.

 

Case Three

The partner of a client who you have been treating for severe depression sends a letter to you. Should you open and read it?

 

The letter received from the partner of the client may be construed to lead to a conflict of interest especially concerning the client’s best interest. If the therapy sessions are ongoing and no information of an immediate emergency has come to light, it would not be pertinent to the process to open and read the letter. When considering the potential legal ramifications of such an action, it can be noted that the client may have recourse against my action if he has any notion of a discussion of his case with the partner without his knowledge or prior consent. Such conflict of interest can be avoided by reaching an agreement with the client about the possibility of discussion with a spouse about the case under scrutiny.

Communication with the client’s partner or other associate, such as a doctor, is regulated according to HIPAA. Prior to the Act, the therapist had to obtain a clear written authorization from the client in order to consult with their doctor or spouse. Some concessions to this rule have been noted subsequent to the Act, which now allows the sharing of clinical information between a therapist and the family doctor that is considered necessary to the client’s psychological improvement. Such an exchange does not require direct consent from the client and is only limited to such clinical information. However, the provision does not extend to personal, or non-professional, information obtained from the client’s partner such as the letter in this case.

From an ethical standpoint, the letter may be considered to be a violation of the principles of confidentiality that should be accorded to the client-therapist relationship. I may not be revealing any information to a third party, but receiving information about the client outside the context of the therapy session may contravene with principles of confidentiality. Furthermore, any information obtained from a non-professional has the potential to have bias usually based on the emotional relationship the source may have with the client. Such a biased point of view may affect my objectivity to the process as it may alter my perception of the client and the issues under consideration.

There are instances in which opening such a letter would be a legally and ethically sound decision. For instance, during payment purposes when such disclosures from spouses are necessary for treatment, payment or practice pertinent to the therapy session. At the same time, considering the client’s background of severe depression, it would be ethical to consider the contents of the letter in cases where self-harm, suicidal behavior or a threat to the safety of others is suspected. However, without such indicators, the client has the legal right to having all sessions and records kept private irrespective of their source. To handle the situation efficiently, I should consider the possibility of seeking the consent of the client to obtaining information from the letter or even inviting the partner for a joint session to discuss issues that may prove to benefit the client in the long run.

 

Case Four

You have worked for several years with a man who has a history of rejection by women.  He has worked through many issues and finally has a suitable and loving relationship. He is very grateful to you and strongly encourages you to attend the wedding.

a. If you decide not to attend, how would you address this with your client?

b. If you decide to attend, how would you address this with your client and at the wedding?

 

Having been invited to the client’s wedding, I may decide not to attend due to several considerations about the potential conflicts in ethics. Most therapists have a strict policy against acquaintances with clients outside the professional setting. Ethical considerations that arise from social friendships between clients and therapists include the formation of new needs arising from a change in the context of interaction. This has the potential to drastically interfere with, or taint, future therapy sessions or the process in general as a result of anxiety and confusion on the client’s part due to his being unsure of boundaries in social interactions. As a mental health professional, my objectivity to any future therapy with this individual becomes questionable as social interaction may lead to counter-transference due to emotional reactions to the patient.

In cases of social interaction after termination of therapy as a result of success of the process, dependencies resulting from a change in trust issues may develop. The client associates with me in a new light and in a bid to reinforce our association with friendship, a multiple role complication arises. Most mental health professionals would therefore discourage such social associations citing the potential for the client needing further therapy with social interface altering the transference issues in therapy sessions prior to this contact. The friendship created in the process may become unpleasant due to other unrelated issues and in such a situation, will cause issues dealt with during therapy to resurface and negatively affect the client. To avoid any misunderstandings with the client, it would be important for me to address these issues with him in a professional context, kindly thank him for the offer and politely decline to attend the wedding.

In case I decide to attend, it will be important to discuss some issues with the client prior to the event. For instance, any attendance will be for the meaning of my presence to the client and will in no way indicate the potential for the beginning of a social relationship between us. Indeed, some therapists propose the benefits of interactions with previous clients citing such relationships as potentially beneficial to both parties with an opportunity to being productive and socially satisfying in the process. However the professional boundaries in such a case would have to be clearly outlined in order to avoid mixed roles or misunderstandings in the process.

If in cases of successful therapeutic processes, a therapist deems that a social relationship will not affect the client in any negative manner, then such an association may indeed be beneficial to both parties. Furthermore, if there are no direct legal or ethical issues emanating from such interactions then they may serve as being an additional avenue to provide support and understanding to the client’s situations. It would be in the best interest of the client, and indeed in my own, to present these issues to the client prior to agreeing to his offer and clearly define terms that would lead to the termination of our professional relationship and how these can be avoided.

 

Case Five

A client has a terminal disease and has decided to stop treatment and all “heroic” measures.

 

The client’s decision to discontinue treatment probably arises from a loss of hope since in their view there are no positive elements that can be associated to their situation of severe anguish and a lack of a possible recovery. Terminal illness affects both the client and the therapist with both individuals being susceptible to feelings of hopelessness as well as pain and anger associated with such situations. It is therefore important to address the issue any expression of this feelings on my part as being transferred to the client with this transference being a possible trigger to the client’s recent decision to stop treatment. This would form the foundation of my analysis of the possible causes of this lack of the client’s will to live. A lack of professional supervision of my feelings would further burden the client’s already heavy emotional toll.

If aspects of depression are noted in addition to the decision, it would be important for me to deal with these, in a possible goal to bring the client to reverse his decision. A combination of psychotherapy and related clinical approaches would suffice as a first-response approach to dealing with this depression. At the same time, liaising with other health providers offering the client his treatment would be important in providing a professional assessment of the risks involved in ceasing undergoing treatment. Such liaisons would be governed by HIPAA with considerations being made to avoiding providing information that would breach the confidentiality with the client. The client should then be directed to addressing how to improve his quality of life by working on any issues of depression and anxiety that may have influenced his decision.

Another possible stressor would be that of an adjustment disorder whereby the client may be demonstrating an unhealthy response to the terminal illness that he may find distressing. In such a case, it would be important for me to seek approaches that are aimed at stress-reduction in a bid to teach the client to cope positively with his situation. This would form the basis of a psychological intervention that would encourage the client to identify and express any emotions of anxiety, fear or hopelessness that he may be concealing. Another possible approach would be that of encouraging him to seek other therapeutic processes such as group therapy and support networks in addition to his current therapy sessions. This would allow the patient to have an additional perspective to his situation from individuals who may be experiencing similar or even worse case scenarios in their lives. By sharing his problem with individuals with similar interests, the client will eventually learn to deal with any stresses he may have and learn to lead a positive life irrespective of the circumstances involved.

 

Case Six

You treated a Native American for alcohol use/abuse several years ago. When you and some friends go to a casino for a weekend, you encounter this person who tells you and your friends that he now has a good job at the Casino thanks to the work he has done with you.  When you go to check out, you are told that your room and dining expenses have been “comp’d.”

 

The offer by the former client to cater for the hotel expenses may be considered a noble act of gratitude but has the potential to have legal and ethical repercussions especially on my part. In a legal sense, some experts may construe an acceptance of this action as a business deal between the client and me or as a form of remuneration for past services rendered. Joint commercial ventures between a therapist and client are frowned upon due to the emotional attachment and the potential for tension between the parties involved. The American Psychological Association for instance, takes a dim view of such associations especially if the commercial actions lead to a form of trade using fiscal remuneration in return for psychological services (Corey et al., 2003).

The consequences of accepting any gifts, irrespective of their monetary value, includes the potential for charges of exploitation by the former client leading to ethical questions of the professional relationship between the individual and I. Further implications of a lack of professional judgment on my part will result from the possible clinical contraindication as a result of my actions. The ‘gift’ offered to me by the client can be construed as being financially consequential thus constituting legal or ethical grounds for a case against my professionalism and competency to deal with receiving gifts from current and former clients as gratitude to my services.

Tokens received on special occasions may be accepted from the client but only if they are not valuable either in a financial or emotional way to the client. However, it is important to understand that accepting such items leaves the therapist vulnerable to a wide array of legal and ethical charges. Most therapists will clearly define remuneration procedures to the client before treatment and will usually decline or forms of payment or gratitude outside the specifications of these agreements. Exploitation charges will usually have clout irrespective of the intentions of the client or the therapist at the time of gift exchange with attitudes and views of the client changing if they deem the therapy process as ineffective to their situations.

To avoid such incidences, it would be important for me to uphold a sturdy professional identity especially when dealing with situations where the client offers a gift or favor as a form of gratitude. Such a conservative approach would involve a diplomatic decline of the gift offered by explaining to the former client that, despite the noble gesture, accepting such a gift would constitute a violation of legal and ethical standards that dictate proper conduct on my part. This would also avoid potential action against my professionalism especially if my action is considered as being the result of solicitation or even coercion of the client to offer me the gift or favor.

 

Case Seven

A female client reports sexual abuse by another therapist.  When you encourage her to report this, she indicates that she wants you to do this, as she does not want to get the other therapist in trouble.

 

Having received the report from the client, the initial process would be to establish whether or not there exist reasonable grounds to indicate that the client has been sexually abused by another therapist. During this process, I will make the client aware of my mandatory responsibility to provide a report in order for a Discipline Committee to scrutinize the actions of my fellow therapist. Health Professions Acts usually require therapists or other health professions to offer a compulsory report when they believe that another member of their profession has sexually abused a client.

It is however, crucial that the client offers consent to this report as well as the identification of the therapist involved. If, as in this occasion, the client declines to reveal the identity of the therapist in such a report, it would be necessary for me to discuss the gravity of the allegations as well as the rights of the client to seek redress for the therapist’s actions. By providing the client with all the information about the situation as well as resources at their disposal, it would also be important for the therapist to convince the client to address the situation at hand and seek further help for it. The first step towards healing would of course involve facing the perpetrator of this act would involve reporting the client offering consent to the report or even reporting the act herself.

It would involve some encouragement on my part in order for me to convince the client to come forward with this information. At the same time it would be important to spell out the procedures of such a case before a Discipline Committee. The client would for one, be required to provide an account of events leading to the sexual abuse as well as the actual violations involved. This would be an intrusive process that would be stressful to the client, but she should be made aware of the support system at her disposal to guide her through the process. In case of a hearing, the client should be made aware of her requirement to testify further adding to the difficulty of the problem.

Sexual abuse in any individual in a professional capacity such as therapy should be frowned upon through legal provisions advocating for severe consequences. The safety of the therapeutic process is violated by such individuals who exploit the client’s vulnerability resulting from unresolved psychological issues. Therapy should therefore be protected from such individuals with any individual using their professional skill in actions leading to the client’s harm being severely punished. The client should also be encouraged to report such actions in order to prevent the therapist from future actions of the same nature that could eventually discredit the entire process of therapy.

 

Case Eight

A fragile female client who believes that she has made great progress would like to enter a training program to become a mental health professional. The client wants you to write a letter supporting her entrance into a training program. You are not sure she is sufficiently mentally healthy to work as a professional.

 

The client should be made aware of the legal ramifications of a referral on my part as her therapist especially as pertains to several confidentiality issues. For instance any information that I provide on her behalf as a mental health professional must include my expert opinion on her current well being as well as any known problems that could prevent her from being effective at the training program. This would constitute a breach of confidentiality as such information would ultimately expose information obtained under the confines of therapy which the client may not want revealed. Judging from her mental condition prior to, and even during, therapy, it would be advisable to seek direct consent from the client in order to reveal such information as it would have the effect of reducing her chances of gaining entry into the training program.

When making such a recommendation, the potential for conflict of interest would be based on information shared in confidence, with the legal implications extending beyond a compromised reputation on my professional judgment. Having presented these issues to the client, I would advise her to consider whether my input will affect her application positively or negatively. At the same time, if her fragility could result in a negative result to herself or to others during or after the training program, I would advise against it and suggest that she seek the career change once therapy achieves its intended success. This would be based on my professional assessment of whether the client meets the requirements of a mental health professional.

On further discussions with the client, I would make sure to point out the requirements for her new career choice and how best, if she is indeed capable, to deal with the issues associated with this line of work. An assessment of her interpersonal skills, how well she analyzes potential situations that she would face in her day-to-day role would be other factors that would have to be considered. Other issues such as how well she handles stressful situations that are commonplace in mental health service provision would also be major indicators of her readiness to give professional advice to other individuals. Given her past fragile mental state, such stresses could trigger relapses of issues that had previously been dealt with during therapy sessions. Her past also leaves her vulnerable to future counter-transference to patients thus becoming harmful to all parties involved.

If, after explaining these issues, the client is still willing to continue with her application, and offers consent to a release of her private information obtained during therapy, the best course of action would be to convince her to seek a psychological evaluation from another therapist regarding her mental and emotional state. The results from such an evaluation would indeed strengthen her case as well as offering a clear perspective of whether or not she is indeed ready to enroll into the training program.

 

Case Nine

You have a private practice and teach graduate students who are studying to become mental health professionals. You are approached by a student in the last class in the program with a request to begin individual therapy with you.

 

As a mental health professional, I should acknowledge the influence that extends to the graduate students who are seeking to become specialists in this field of service. This would be the case with the student who proposes to begin individual therapy as this student may look up to me in my role as a teacher but is willing to extend this association to that of a therapist. The ethical repercussions that would be as a result of this dual-role relationship could be manifested in undefined areas such as the student expecting special favors on my part due to prior associations. For instance, during the therapy process, the student may request for a letter of recommendation in my capacity as a professional lecturer that may conflict with my interests in the therapeutic process.

At the same time, a prior bias may exist from the student’s academic profile which would limit the objectivity of the entire process of therapy. Indeed, most therapists with teaching capacities in institutions of higher learning would encourage the student to seek counseling from other avenues that may be provided at the school or in the community. To ensure that a possible dual-role conflict does not arise, it would be important for the student to stipulate that I would not offer any evaluations of any academic nature in my role as a lecturer. This would include any help gaining entrance into another institution of learning or a training program requiring a referral from me in my capacity as a mental health professional. However, even with such legalities in check, such an association would leave several ethical issues still not dealt with that would negatively affect the individual therapy.

The APA, for instance, stipulates multiple role relationships have to be resolved with the best interests of the individual while avoiding any ethical consequences. Therefore, each situation would be handled according to the therapist’s opinion of the potential problems while dealing with avoiding emotionally or mentally diminishing the student in the process. However, in the defense of the process of individual therapy in this case, a professional association between the teacher and student is ending and would therefore not conflict directly with that of the therapist and his client. Such a professional relationship could serve beneficial to both parties involved and especially to the student who may seek professional help from an individual he may trust.

It would be usually advisable to take up the offer of the student since in cases where the relationship deteriorates the student will have lost a valuable academic asset. Such a case can be avoided by providing the student with clear guidelines on the new relationship involved in individual therapy, or refer the student to another qualified profession who has no prior interaction with the student.

 

Case Ten

You have worked with a client who is a fellow professional. You both agree that you have much in common.  The client has made excellent progress, and has terminated therapy. What should you do when, shortly after treatment has terminated, the client calls and suggests that you purchase season tickets for a series of theatrical performances?

 

Having terminated the treatment in recognition of the successes of the process, one may take the possibility of friendship and social association with the former client into consideration. However, the risk of multiple role complications does exist, especially as a result of the change of context in association from a professional to a social capacity. Critics of such involvement would cite the possibility of the client requiring future therapy but the success of the same being hindered due to acquired transference outside the confines of therapy. If the friendship takes a turn for the worse, the client may exhibit relapses with elements of issues dealt with during therapy resurfacing and being added to doubts in the therapist’s professional capacity to deal with them.

The change in association from that of professional therapy to a more social interaction will involve a change of dynamics that the client may not be equipped to deal with. For instance, boundary changes involving personal issues raised during therapy may confuse or even harm the client. My objectivity in any future therapy with the client will thus be compromised with the best interest of the client being that of dealing with another professional. An added advantage from this situation would be since the client is a fellow professional, an explanation of the risks involved in social interaction would be easier. At the same time, it would have to be understood by both of us that the possibility of future therapy would be out of the question and that any such requirements would be directed to an able colleague.

In case this change in roles has the potential to affect the client in any negative way, then it should be discouraged fervently. At the same time, any legal or ethical vulnerability such as the perception of taking advantage of the former patient should be clearly outlined and avoided at all cost. However, despite these implications on both parties, proponents of friendship after therapy would cite the potential of such interactions to be beneficial to each individual. Taken outside the context of therapy, I could gain a satisfying and productive friendship with this individual especially considering that we both have much in common.

However, such interaction would clearly be defined according to professional and ethical boundaries clearly outlined before accepting the client’s offer. At the same time, such a friendship should pose no identifiable risk to the gains made during therapy and should involve the absolute termination of any professional obligations demanded between the two of us. If all these issues are discussed and agreed by both parties, and no further legal or ethical obligations are required in a professional capacity, then an acceptance of the client’s invitation would be appropriate.

Reference

Corey, G., Corey, M. S. & Callanan, P., (2003).  Issues and ethics in the helping professions, (7th edition), Pacific Grove, CA:  Brooks/Cole Publishing Co