This workshop is based on discussion of ethical issues
raised by clinical vignettes such as those below,
adapted and used used with consent from a state psychological association.
Others sources will also be used.
1. To use provided clinical vignettes to practice how to recognize the ethical and legal issues.
2. To use suggested categories to consider options for ethical response to the dilemma.
3. To provide hypothetical vignettes based on ethical/legal dilemmas in my own practice.
Therapist In The Middle
In a therapy session in an outpatient substance abuse treatment facility, a patient reveals that an agency staff person — another therapist in a different department — has paid to have sex with another patient in the treatment facility — Lyla, who is a prostitute.
According to the therapy patient, Lyla is not aware that one of her customers is a therapist who works in another part of the same facility where she is receiving substance abuse treatment.
The therapist who received this information does not know the other therapist well, but has provided some consultation for the therapist in the past.
The therapist does not dwell on the situation with the patient. However, after the session, the therapist feels uneasy about what his patient revealed.
What are some of the potential ethical pitfalls in this scenario?
Does the therapist who hears this information have any legal obligations?
What, if anything, should the therapist do?
A Suffering Caregiver
A colleague of yours, Dr. Solomon, contacts you for advice regarding a new client she has just seen. The client, Mr. Don Tellanyone, is a 47-year-old man who is seeking services for depression. During the initial phone contact, he asked repeatedly about privacy and wanted assurances that information discussed in session was confidential. The patient repeated this line of questioning during the first face-to-face session.
As the session progressed, he revealed that the source of his depression was the death of his mother one year ago. His mother had suffered from a combination of severe respiratory problems and Alzheimer’s. Mr. Tellanyone had been caring for her and his father in his home for 6 years prior to her death. During the last two years, she required total care. He revealed that she had been suffering greatly and, out of compassion for her, he gave her an excess dose of her sleeping and pain pills. Medical personnel never questioned the death as the woman had been quite sick and “It was only a matter of time.”
Mr. Tellanyone goes on to explain that he is now caring for his father in similar circumstances, although there is no dementia. His father has declined rapidly since the death of his wife and now requires total care. Mr. Tellanyone reveals that recently he had a conversation with his father in which the father commented how peaceful his wife’s death was and how he hoped for a similar passing.
Mr. Tellanyone is feeling quite guilty about his mother. Simultaneously, he strongly believes he made the right decision. He would like help to work through the issues. He is also very concerned about confidentiality and wants assurances from Dr. Solomon.
Dr. Solomon, feeling uncomfortable with the situation, contacts you for a consultation about the potential ethical issues for this case.
What are the potential ethical issues in this case?
Are there legal issues in this case?
What would you advise?
A new referral?
A therapist had an intake appointment with a new client. As soon as he looked at the intake form, he realized that she is the ex-wife of his former client. The therapy with the ex-husband was brief, and he focused on how he wanted to leave the marriage. The prospective client was using her maiden name and gave no indication during the session that she knew about her ex-husband’s treatment with the therapist.
When asked about the reason for the referral, she said that her physician had referred her for anxiety. She mentions that she is still in communication with her ex-husband because they share three children.
What are the ethical issues for this scenario?
What emotional reactions may occur for the therapist?
Should the therapist treat the woman?
A Therapist in Turmoil
A therapist is treating a client who is involved in a legal proceeding. The client presents the therapist with information about a well-known, local therapist who released confidential information about him to an attorney without a signed release or court order. After reviewing the information presented, it is clear to the treating therapist that the other therapist breached confidentiality.
Both therapists are of the same profession. The treating therapist knows the local therapist who released the information, but does not have a strong relationship with him. The treating therapist is questioning what to do.
The treating therapist believes the options are:
- Address the matter with the other therapist directly.
- Refer the matter to the State Board of Psychology.
- Encourage the client to file a complaint with the State Board of Psychology.
Are there any other options?
What are the possible emotional reactions to this situation? And, how would you, as the treating therapist, deal with those emotions?
What is a likely course of action?
A Tricky Situation
Dr. Smith is a therapist who has worked with a young woman for about 9 months. The patient presents with a history of rejection and abandonment as well as being abused by persons of power. She recently received an offer to become a sales representative for a pharmaceutical company. The therapist and patient discussed the type of job she was entering, because knew she might experience rejection from doctors, nurses, and other office personnel.
After her 6 weeks of training, the company assigns her to a regional director that the therapist knows personally. Along with the initial anxiety of the new job, her territory, and her boss, she reports a fear of failure and other anxiety related symptoms. The therapist knows her new boss, Mr. Biggy. The therapist seeks to reassure the patient that he, the therapist, knows Mr. Biggy on a personal basis and that “he is a really a good guy” that seems bright, friendly, and fair. He indicates that Mr. Biggy is a good “family man.” The patient is reassured, and reported less anxiety. In actuality, Mr. Biggy’s wife is a very close friend of Dr. Smith’s wife. They have dinner as couples several times per year.
Several weeks after beginning to go on sales calls, your patient reports that Mr. Biggy is complimenting her on the way she looks and her ability to make the sale. They start spending more time together. However, she begins to feel uncomfortable as she feels like they are spending too much time together. Mr. Biggy starts asking questions that are more personal, forwards her “funny” emails, and texts some inappropriate remarks to her, mainly about her alluring power that helps make sales.
Mr. Biggy and Dr. Smith meet in an unplanned social venue. Mr. Biggy pulls Dr. Smith aside and explains how he has become very attracted to a new sales representative. He thinks that she is young and impressionable. He confides that he would like to have an affair with her.
Dr. Smith politely explains that he feels uncomfortable with them discussing his more personal marital issues. Mr. Biggy indicates that he wants to talk more about his feelings. Dr. Smith suggests a referral to a therapist, but Mr. Biggy states that he feels more comfortable talking with Dr. Smith. After some other small talk, Dr. Smith leaves to mingle with other friends.
Dr. Smith is now worried about the entire situation.
In hindsight, what triggered some possible difficulties in this situation?
What are the ethical issues involved in this scenario?
How are the client’s emotional and interpersonal issues related to the therapist’s dilemma?
What are the options for the therapist for both his relationship with his patient and his relationship with Mr. Biggy?
Referral and Treatment Boundaries
A therapist receives a phone call from a well-known internist in her area. The therapist is involved in a busy practice, specializes in treating eating disorders, and receives only occasional referrals from this physician. The physician wants the therapist to treat his 17-year-old daughter, who suffers with what he describes to be an eating disorder and perhaps some Borderline Personality Disorder traits.
The physician explains that he has been medicating her for about four months with Prozac and Klonopin, once he became aware of her eating disordered behavior. Because of his status as a well-known internist, he does not want to refer his daughter to a psychiatrist because he believes that he can handle the medication piece of her treatment. He will also pay for all treatment in cash, as he wants as few people and organizations to know about his daughter’s issues.
Feeling somewhat uncomfortable with the medication management issue, the therapist indicates that she will have to look at her schedule and call him back. The therapist then phones you for an informal consultation. The therapist expresses her concerns about working with a patient whose father is prescribing medication.
Are there any ethical considerations in this dilemma?
What are the potential pitfalls in the scenario?
What are potential advantages in this scenario?
What are some of the suggestions that you may have for the therapist about accepting or declining the referral?
What concrete steps might be important before calling the physician back?
Are there additional considerations for how to approach the referring physician when calling back?
An Invitation to Assess
You are checking your email after a busy day. The following email catches your attention.
From: PsychBuilder – High Tech Psychology at Low Cost
Sent: Monday, November 10, 2011 6:37 PM
Subject: Online Assessment Tool to Promote your Practice
My name is Dr. Rob West, President and CEO of PsychBuilder Inc. located in San Jose, California. My company has developed a unique opportunity for you and your associates. PsychBuilder Inc. developed the first internet-based administration and scoring of the Personality Assessment Symptom Scale-2, the PASS-2. Therapists have used the PASS-2 for psychological diagnoses and evaluations for a number of years. The PASS-2 is administered online, from any computer, iPad, or iPhone. The test usually takes approximately 40 to 60 minutes to administer. Results will be available to you and the patient online.
Important to an entrepreneurial therapist like you, this assessment bridges the gap between psychology and primary care. Numerous patients from family practice offices can be given the internet link and a security code to complete the PASS-2. The test is designed to determine if the patient can benefit from psychotherapy, psychotropic agents, or other psychological services. While it is not a complete assessment, it can guide patients to you for further psychological consultation. After a patient completes the assessment, an email will be sent to you (based on the security code) and the patient within 24 hours, providing a secure link to review the results of the PASS-2. Patient contact information will be part of the administration process.
The cost of the online administration is $25, to be paid by the patient. For this to be a successful venture, we ask you to promote this program to your referring physicians, nurse practitioners, and physician assistants in order to enhance their ability to identify, evaluate and provide needed treatment for their patients. We have great data on the PASS-2 for reliability and validity in identifying primary care patients who can benefit from psychological services. Unfortunately, many patients struggling with mental health issues in primary care settings are not properly identified or treated. Because of busy primary care practices, the PASS-2 can be completed at home, if the office does not have internet access for patient use.
The physician, nurse practitioner, or physician’s assistant will offer patients this important opportunity via a specially designed 4 x 6 card. On that card, there will be information that explains the importance of completing this assessment, the cost, and that a licensed therapist will review the results and contact the patient by phone within 3 to 5 business days. An important factor is that there is no cost to you, as the therapist. You will receive a high quality report that offers diagnostic possibilities, suicide potential, and treatment planning options for new patients. I encourage you to review our web site. If you have further questions, feel free to contact me.
Robert West, PhD, ABPP, Therapist
What are potential ethical issues with this invitation?
What clinical concerns arise for you in this scenario?
What should you do with this email solicitation?
What would you likely do with this email solicitation?
A Session with the Spouse
Dr. Faye Miller receives a referral for a 35-year-old female, Betty Drapier, who is feeling depressed and experiencing marital problems. During the first few sessions, Mrs. Drapier indicates that her husband, Don, is depressed and in treatment. Part of her struggle is that she sees her husband as more depressed now than when he started treatment. By Mrs. Drapier’s report, he appears more stressed because of his job and is drinking alcohol more frequently. She reports that the husband’s treating therapist, Dr. Cooper, has allegedly advised him to discontinue his medication in favor of an herbal remedy (St. John’s Wort). Dr. Miller suggests that she meet with both Mr. and Mrs. Drapier to evaluate the marital situation.
At that time, Dr. Miller not only wanted to evaluate the marriage, but to evaluate how impaired the husband was, and to decide whether Mrs. Drapier had assessed her husband’s depression and the marriage accurately.
During the next session, Mr. and Mrs. Drapier arrive separately, but on time. Mr. Drapier acknowledges many cognitive, behavioral, and physical symptoms of serious depression. Mr. Drapier smelled as if he had been drinking, and he admitted that his alcohol use has increased. He also divulged that his risk-taking behavior has increased as well, such as speeding. During the session, Mr. Drapier verbalized suicidal ideation in a flip manner (“Sometimes I think it would be better if I just killed myself”). The marital situation appears deteriorated and Mr. Drapier appears significantly depressed.
As the session winds down, Mr. Drapier spontaneously asks for a second opinion about his treatment with Dr. Cooper. He indicated that Dr. Cooper recommended that he discontinue a psychotropic medication in favor of an herbal remedy. Mr. Drapier mentions that Dr. Cooper sells St. John’s Wort to him directly.
After reiterating the purpose of the session (which was to assess the marital situation and not to assess his current treatment), Dr. Miller states that she feels uncomfortable with the request, although she is concerned about the therapist’s reported behavior. She is also concerned about Mr. Drapier’s level of depression, alcohol use, and suicidal statement.
Abruptly, Mr. Drapier looks at his watch and leaves the office explaining that he is late for a business meeting.
What are Dr. Miller’s potential ethical issues in this situation?
What are some actions that you, as the treating therapist, may have done differently?
If you were Dr. Miller, what are your emotional reactions to this situation?
What obligations does the therapist have to Mr. Drapier, Mrs. Drapier, Dr. Cooper, and the public?
Therapist as Character Witness?
A therapist receives a phone message from a former patient. The former patient is asking for the therapist to be a “character witness” as he has an upcoming hearing for a minor criminal offense. His attorney believes that some good, written character references will really help out with the case.
The therapist pulls the former patient’s chart. The therapist has not worked with the patient for about two years. Additionally, none of the treatment issues had to do with impulse control or antisocial tendencies. Therapy lasted about a year and focused on depression and relationship issues. The therapist recalls that the patient had always been good-natured, attended appointments regularly, and worked well in therapy. The therapist remembers the former patient as a likeable person.
How would you feel about receiving this request?
What ethical issues are involved?
What are your potential options?
If you decide to provide information, would you consider communicating with the prior patient’s attorney? What would you need from the attorney?
Multiple Relationships Revealed
A female therapist in a suburban area has worked with a male patient for about one year. They agreed to meet weekly for the first four months of psychotherapy, and then they agreed to meet twice per month. They developed a good therapeutic alliance. During the course of their work, the patient discussed significant facts about his troubled past, numerous details about failed past relationships, and sexual fantasies. The main therapeutic issues are depression and loneliness.
During the current session, the confides that he has made a new female friend. As social isolation, loneliness and depression are regular themes in treatment; the therapist frames this as positive progress.
As the conversation continues, the therapist is surprised to learn that the patient’s new friend is the ex-wife of the therapist’s husband. The patient reveals that he became aware of that information after several dates and recently felt comfortable revealing this to the therapist. He also indicated that the relationship is taking on a more serious tone.
The ex-wife moved back to the area about six months ago. The therapist knows that the ex-wife had been struggling with isolation and loneliness as well. The therapist, her husband, and his ex-wife are on good terms. They see her regularly for informal family events and do holidays together with their adult children and grandchildren.
After the session is over, the therapist has time to reflect on her concerns. The therapist feels stuck and overwhelmed by her present situation. She calls you for an ethics consult.
What are the ethical issues involved?
What would you suggest that she does?
With whom does the therapist discuss the multiple roles?
With only the patient?
With the patient and the ex-wife?
With her husband, the patient and the ex-wife?
Can the therapist continue the treatment relationship with the patient?
Even if they terminate therapy, how does the therapist cope with family gatherings since she knows significant details about her patient’s life?
An Unexpected Inheritance
A therapist receives a letter from an attorney indicating that he has inherited an old car from Frank Palmer. Upon reflection, the therapist recalls that he had treated Mr. Palmer a number of years ago. Looking through his files, the therapist cannot find his file, so it must have been more than five or six years ago.
The therapist phones the attorney and discovers that Mr. Palmer left him a 1993 fourwheel drive Ford Explorer. He asked the attorney if anyone is contesting the will. Apparently, no one is. The executor is Mr. Palmer’s brother, who lives in a different state.
The therapist obtains the keys and title for the vehicle. He drives the car to a local dealer who indicated that the Explorer is worth about $3,500.
The therapist cannot remember many details about the patient. He recalled that he was an older person with significant depression who eventually became better. There is nothing unusual that stands out about their therapeutic relationship.
Feeling guilty, the therapist calls you on the phone to discuss his feelings and any possible ethical concerns.
What are the potential ethical concerns about this scenario, if any?
What suggestions or recommendations would you offer to the therapist?
A Request for Assistance
Dr. Lilith Crane, a therapist in the counseling center of a small rural campus, calls you on the phone for a consultation.
Dr. Crane currently works with an undergraduate student, Dan, on issues related to selfesteem and depression. An ongoing theme in therapy revolves around his sexual orientation. Dan recently came out to his parents, who were accepting of his gay orientation and lifestyle. From that positive experience, Dan wants to start a support organization for other GLBTQ students on campus.
Dan explained to Dr. Crane that this group would be student-led and meet on campus. He does not view it as a therapy group. Dan’s vision is that the group would meet periodically to provide one another with support, to do problem solving, to share information and personal struggles, and perhaps to provide some psycho-educational work on campus. Dan indicates that they may also want to engage in fundraising in order for GLBTQ students to attend state or national events.
Dan asked a number of faculty members to be the faculty advisor of this group. While most were supportive, all declined the invitation (likely because the campus is small and in a conservative area of the state).
Out of options, Dan is asking Dr. Crane to be the faculty advisor. Dr. Crane applauded and appreciated the student’s energy and creativity, but indicated some concern about dual role with the student. She told the student that she would think about the request prior to answering.
Dr. Crane is questioning the pros and cons of being the therapist and the faculty advisor. Dr. Crane feels ambivalent because of their therapeutic relationship, but also wants to help Dan because he appears to have limited options.
What are the possible downsides to entering the dual relationship?
What are the possible steps Dr. Crane can take to mitigate any potential difficulties?
What are other steps that the therapist may want to take in this situation?
Troubles in the ICU
You are a therapist in a busy acute care hospital where you receive
frequent consultation requests by the trauma service. A physician requests a psychological evaluation of a 46-year-old man who attempted suicide via overdose of prescription medications along with alcohol.
You arrive in the intensive care unit where the patient’s respiratory status is rapidly deteriorating. He is marginally coherent and unable to give any consistent responses. However, upon his arrival in the emergency department, the medical record quotes the patient as saying, “This wasn’t supposed to have happened.”
The ICU nurse asks you to offer an opinion regarding the patient’s capacity to accept or refuse intubation.
While you are there, a family member arrives with a copy of a notarized advance directive, created within the last year, which specifically outlines the patient’s wishes not to be placed on a ventilator or any artificial life support. The ICU staff asks for your input.
What are the ethical issues involved?
What would you do in this situation?
Would your answer differ if the advanced directive was created 7 years ago or greater?
Would your answer differ if there were no advanced directives?
The Psychology of Advertising
Dr. Ron Popeil, a local therapist, is upgrading his web site. Along with
a variety of upgrades, the web developer/consultant suggests that he add a testimonial page where former patients describe their positive experiences in therapy. Since the web developer/consultant wants to get that page up and running, he suggests that they use some positive ratings and responses from Angie’s list and several other online rating sites that tell positive stories and experiences with Dr. Popeil.
Dr. Popeil thinks these ideas are good. However, he researches the APA Ethics Code and believes that he may be acting inappropriately. To discuss the matter in further detail, Dr. Popeil calls you for an ethics consult.
What are the ethical issues involved in this situation?
Are there any other concerns about the web developer/consultant’s strategies?
What are some recommendations that you would make to the psychologist?
To Evaluate or Not To Evaluate
Dr. Joel Bishop has been conducting pre-ordination evaluations for a religious institution for many years. The purpose of these psychological evaluations is to identify individuals who have gross psychopathology, strong personality disorders, or other characteristics that would make them incapable of performing their religious duties adequately. Dr. Bishop developed a strong relationship with this religious institution and they have been quite satisfied with his work.
One day, Dr. Bishop receives a phone call from his contact at the institution. The contact is now requesting that Dr. Bishop begin to screen individuals for “homosexual tendencies” because, according to the doctrines of the denomination, such individuals are not eligible to become clergy.
Dr. Bishop feels uneasy about this situation, as “homosexuality” has not been considered a mental illness since the 1970s. Simultaneously, the religious institution is adamant about this requirement.
Dr. Bishop calls you for a consult about this situation.
What are the ethical issues involved in this scenario?
If you were the psychologist, what would be your emotion response to this situation?
What are some potential responses that you could offer Dr. Bishop?
A therapist receives a call from an attorney wishing to seek services for depression, anxiety and substance abuse. The therapist screens the potential patient and believes that she can help him. When she asks about insurance, he indicates that he will pay in cash. The therapist explains the fee structure for the initial appointment as well as ongoing psychotherapy sessions. The lawyerpatient comments that this seems low. The therapist ignores the comment and finishes by setting their initial appointment.
The therapist and the attorney-patient meet for the initial session. At the end of the session, the therapist asks for the requisite fee as stated on the phone. The attorney-patient indicates that he earns about 2.5 times what the psychologist asked. He indicates that, in order for him to benefit from the treatment, he feels a need to pay what he makes an hour. He also states that if she does not accept what he is offering, he will lose respect for her as a professional and probably not return for treatment.
Not knowing what to do, and realizing that the next patient is in the waiting room, the therapist takes the cash and sets up another appointment. At the end of the day, the therapist reflects on the interaction her new lawyer-patient. She does not feel right taking a fee larger than her usual and customary rate. She is struggling that the situation is not right and feels very uneasy about the arrangement that the lawyer-patient foisted upon her.
Uncertain, she calls you for an ethics consultation.
What are the ethical issues, if any, involved in this case?
What would be your emotional response to this situation?
What factors make this situation potentially difficult for you as a therapist?
What factors make this situation potentially easy for you as a therapist?
What do you believe is the best course of action?
Titles, Roles and Boundaries
Dr. Thomas is a mental health professional who is a part owner of a private group practice, some members of which offer Employee Assistance Program (EAP) services. The EAP service provides a solution-focused, three-session benefit for companies within Virginia.
Dr. Thomas normally does not handle EAP services, but today several staff members are either ill or overbooked, so Dr. Thomas responds to EAP requests during the day.
When dealing with the EAP program, she thinks her title of “doctor” might put people off, so she announces herself as “Sue” when dealing with EAP clients. When returning a call from Chuck who works for a company with the EAP benefit, the psychologist indicates that she is “Sue” from the EAP program. Chuck is a 20-year old man who immediately expresses a great deal of agitation and anger. He complains loudly about his parents and his girlfriend. In the process of conversation, Dr. Thomas realizes that Chuck is the son of her next-door neighbors. While Chuck now lives in an apartment in town, she remembers him well. She actually attended his graduation party briefly and hired him to cut her lawn for two years.
Also during the course of the phone contact, Chuck expresses some homicidal rage toward his parents, particularly around financial issues and early childhood sexual abuse from his father. Dr. Thomas wants him to come in immediately for a more indepth evaluation. Chuck hesitated to have a face-to-face interview at the practice, but agreed only if he can talk with Sue. Sue schedules the appointment for early in the evening.
What are the ethical concerns in this scenario?
How would you advise Dr. Thomas to handle them?
If you were a co-owner of the business, how would you feel about this situation?
Co-authorship with a Former Patient
Dr. Jordan is a therapist who typically works with a wide variety of patients. At the end of the day, he listens to voicemail messages to learn that a former patient is reaching out to him for a request.
Prior to returning the call, Dr. Jordan reviews the patient’s chart. The patient had been in treatment for about 10 months on a weekly basis. The patient was in therapy for approximately one year. The treatment notes indicate that she dropped out of therapy about one year ago. She stopped therapy because her insurance changed and Dr. Jordan was not an in-network provider. The therapy focused on depression and anxiety related to work-related issues, interpersonal limitations, and relationship difficulties. Some of the sessions focused on a sexually abusive relationship between a basketball coach and the patient when she was age 13 to 16.
Dr. Jordan returns the phone call. After the initial greetings, the former patient indicates that she has finally started to write down more thoughts, memories, and recollections about her abusive experiences. She stated that Dr. Jordan recommended that she write down her memories. She recalled that he agreed that it could make a good book. She stated that she wanted to include some education around sexual abuse and tell her story in a healthy, therapeutic manner.
When Dr. Jordan attempts to clarify the request, it becomes clear that the former patient is not asking to return to therapy, but instead is asking Dr. Jordan to become the co-author or a consultant for the book. Dr. Jordan thanked her for the compliment and indicated that he needed to think about the request. He promised to call her back within a week.
Dr. Jordan calls you on the phone for an ethics consultation.
What are the ethical issues involved in this case?
What are some possible suggestions for Dr. Jordan?
If you were Dr. Jordan, how would you feel about this request?
A Missing Patient
A therapist has been working individually with a 17-year-old male for issues related to depression and family dynamics. The therapist and the young man have been engaged in psychotherapy for the past 2 years. The patient has trust issues with his parents, especially his father.
Ten minutes prior to the next scheduled appointment, the patient’s mother calls the therapist on the phone. The mother explains that the child has run away and the mother has reported the child missing to the police. The mother further reports that the patient’s cousin has been driving the patient around town. She wants the therapist to phone the police immediately when the patient arrives and to have them arrest the cousin for unlawfully detaining the minor child.
After the phone call, the therapist checks the waiting room and sees the patient there. He is talking with a young man, most likely his cousin.
What obligations does the therapist have to the parent?
What is the therapist to do?
What are some likely emotional reactions would you have in this situation?
Has the Psychologist Done too Much?
Dr. Plenty lives and practices psychotherapy in a rural area. She began to provide psychotherapy to Mr. DiMencha, a 52-year-old, who suffered with depression. After six sessions, Mr. DiMencha suffered a significant concussion while at work. His impairment is noticeable by Dr. Plenty without any type of testing. He struggles with understanding concepts and his conversation becomes tangential during the next two sessions.
Mr. DiMencha’s co-worker, Janet, helped him find an attorney so that his rights are protected. Dr. Plenty had Mr. DiMencha sign a release giving consent for him to talk with the attorney as well as Janet. From a phone call with the attorney, he learns that Workers Compensation wants to work out a settlement. However, the attorney has little awareness about how impaired Mr. DiMencha is. The patient has never met the attorney face-to-face, only by email and phone contacts.
Mr. DiMencha demonstrates a variety of cognitive deficits. He needs assistance and monitoring with daily tasks, such as home care, shopping, transportation, understanding the settlement process, reading his mail, and paying his bills. He will likely need to go into an assisted living facility. His family lives at a distance and provides minimal help. Workers Compensation refuses to pay for the case management services of an independent social worker. Attempts to find social service agencies able to help him have not been successful. Mr. DiMencha doesn’t appear to understand his legal rights or the settlement process.
Prior to providing extra-therapy support, Dr. Plenty had Mr. DiMencha sign a document explaining her fees for the additional services. She is not sure that he completely understands what is happening or understands her version of informed consent for the additional services. She has been doing much of the case management work, e.g. locating a long-time friend who is willing to help him at home, referring him to a neuropsychologist for testing, engaging in lengthy discussions with his primary care physician and neurologist, participating in multiple conversations with the attorney, and trying to find a guardian or power of attorney.
In the midst of all of this activity, the psychotherapist contacts you for an ethics consultation.
What are the potential ethical issues with this case? Are there competing ethical principles?
Is Dr. Plenty acting beyond the limits of her competency? outside her scope of practice?
What problems may occur as a function of Dr. Plenty engaging in a multiple relationship role in Mr. DiMencha’s care?
A Phone Call from a Friend
Dr. Goodfriend receives a call from Buddy, his very close high school friend. Dr. Goodfriend speaks with Buddy about once every six to nine months. During those calls, the conversations typically focus on careers, family members, and the whereabouts about other classmates.
Buddy phoned Dr. Goodfriend in an apparent emotional anguish by the tone of his voice. Buddy states that he has been feeling “stressed” over the last month. He explains that he recently lost his job and has been worrying about the financial impact that this is having on his family. Buddy adds that he has had trouble sleeping, has stopped exercising, has little energy, and fleeting thoughts of hurting himself. Buddy also shares that he has been short tempered with his wife and kids.
During the 90-minute call, Dr. Goodfriend tries to be a good listener, empathizes with Buddy’s difficult situation, offers advice on ways that Buddy can better manage his stress, provides him with general encouragement, and suggests a book that outlines stress management and anxiety reduction strategies.
At the end of the call, Buddy tells Dr. Goodfriend that he is feeling much better. Just as he is about to hang up, Buddy says, “Thanks. My wife told me that I should see a therapist but I told her that I could talk with you and that it would be much cheaper.”
Dr. Goodfriend is unclear whether Buddy is serious or joking.
If you were Dr. Goodfriend, how do you feel about the phone call?
Does Dr. Goodfriend need to phone his high school friend to clarify his last comment?
Does Dr. Goodfriend need to encourage Buddy to become involved in therapy if symptoms persist?
Should Dr. Goodfriend call Buddy and offer a few referrals?
What factors influence this decision?
A Duty to Report?
Dr. Tell worked with a woman for several months on issues related to depression, anxiety, and relationship issues. During one session, the patient indicated that her boyfriend has lost interest in sex and became more involved with online pornography. While discussing these issues, the patient suddenly stopped talking. Dr. Tell allowed several moments to pass before asking the patient what was happening.
The client indicated that she was hesitant to speak about the issue for fear of a breach of confidentiality. Dr. Tell reminded her about confidentiality and the laws in Pennsylvania that would override it. The client continued to struggle. She eventually blurted out that, during a heated discussion, her boyfriend indicated that looking at online pornography was not as bad as what his uncle did. She went on to detail how her boyfriend described how his uncle was involved in collecting and distributing child pornography but remained faithful to his aunt. The client’s boyfriend expressed that she should never discuss this with anyone. The client asked if she could just give Dr. Tell the information about the uncle so that she could report it to the authorities and leave her out of the situation. The client is feeling very helpless and vulnerable about this bind.
Dr. Tell explained that the alleged perpetrator was several times removed from their sessions and she did not believe that she had the obligation to report it. The client then asked if she could invite her boyfriend to the next session so that they could all discuss the information and the best way to handle the situation.
Dr. Tell focused the client on her dilemma as well as the relationship issues with her boyfriend. Dr. Tell agreed to contact someone to discuss whether Dr. Tell had to report this information to the police or Child Protective Services. And, Dr. Tell agreed to determine whether or not reporting this information would put her client’s confidentiality at risk. She also agreed to think about the need to bring in the boyfriend, because inviting him to therapy will not necessarily help the situation.
Dr. Tell contacts you with the above scenario.
- How would you feel if you were Dr. Tell?
- How would you feel if you were the consultant?
- Is Dr. Tell a mandated reporter in this situation?
- As a mandated reporter, would Dr. Tell report place her client’s confidentiality be at risk?
- If Dr. Tell is not a mandated reporter, should Dr. Tell bring in the boyfriend gather more facts so that Dr. Tell can report the alleged crime?
- Is the goal of therapy to help the client manage the situation or is the responsibility now on the psychologist to gather more information about the possible crimes committed with children?
- Can the client contact Child Protective Services anonymously in this case?
- Can the psychologist contact Child Protective Services anonymously, provided that the client supply the name and address of the uncle?
- What should Dr. Tell do?
A Simple Request
Dr. Smith was treating Mrs. Simpson for depression precipitated, in part, by a separation and pending divorce. There were contentious issues dealing with the custody arrangements of the children. A court appointed custody evaluator performed a child custody evaluation. Among other things, the report contained a psychological evaluation of the patient.
Mrs. Simpson thought it would be good for Dr. Smith to review the report in order to help him with their therapy. Mrs. Simpson read the report and admitted that she did not understand some of the psychological jargon used in the report and had difficulty understanding what the conclusions of the report were.
Dr. Smith decided to review the report. He believed that the custody evaluator had made several significant errors in the report concerning the psychological health of his patient. Additionally, Dr. Smith believed that some of the conclusions were in error, and had little support for those opinions in the body of the report.
Prior to their next session, Dr. Smith calls you for a consultation.
Dr. Smith asked if he needed to inform the patient of his impressions of the report and the seemingly erroneous conclusions. He feels stuck between being faithful to the patient and her needs without crossing a boundary as a treating psychologist.
He also wondered if he should contact the patient’s lawyer, with her permission, to disclose his perceptions about the quality of the report and his perceptions about the conclusions.
Dr. Smith also wondered if it was appropriate to bill Mrs. Simpson for his time in reviewing the report.
Dr. Smith also asked if it is ethical to bill the patient’s insurance company to review his impressions of a forensic report during a psychotherapy session.
Dr. Solomon, a psychologist on an inpatient psychiatric treatment team, is concerned about the pending discharge of a current inpatient. The patient admitted herself to the unit, with some persuasion by the local police, for making loud threats and menacing gestures in her neighbor’s driveway. Hence, the admission is voluntary.
Currently, the patient is denying the fact that she has made past threats toward her neighbor. However, the police report indicated she has made such verbal threats in the past but also, on several occasions, has damaged her neighbors property including scratching the paint on their car and throwing rocks at their house. Innuendos are that she allegedly killed her neighbors pet, but this has been unproven by the police.
During some individual time, the patient indicated to the psychologist that she has “had it” with her neighbor and has “something planned that will make you all finally understand” once she is discharged.
While the treatment team does not share Dr. Solomon’s concern and has started to make discharge plans, they have not spent as much individual time with the patient as Dr. Solomon. In fact, the patient has made no such comments to anyone else other than to Dr. Solomon and has been a model patient on the unit. The days allocated for her stay by her insurance are ending in two days. The attending psychiatrist concurs with the discharge plan and advised Dr. Solomon “not to worry about it.” In fact, the psychiatrist encouraged the psychologist to omit any reference to the patient’s comments about the neighbor in treatment summaries or clinical notes as “hysterical nonsense.”
What are the ethical issues involved?
If you were the psychologist, how would you feel about the situation?
What steps does the psychologist need to take?
How easy or how difficult would it be to take those steps?