Wilcoxon Chapter 8- Contemporary Ethical Issues: Practice Matters

Objective of the chapter: To examine ethical issues associated with common contemporary practice concerns.

This chapter offers discussion and recommendations for therapy matters associated with the following:

• Multiple relationships with clients and others
• The various uses of technology in therapy with couples and families
• Confidentiality, welfare, and protection considerations for clients reporting HIV/AIDS conditions
• Research and publication as a means of informing ethical practice

Multiple Relationships with Clients or Others

A multiple relationship is where an MFT assumes two roles with a client. 

This can be a problem because they are sometimes unavoidable, difficult to recognize, and could either be potentially harmful or beneficial. 

They can be simultaneous or sequential

Ethical Codes and Multiple Relationships

All codes and standards indicate that multiple relationships may be harmful, exploitive, and need to be handled especially since sometimes they are unavoidable, especially if you live in a small/rural community.

Never engage in a sexual relationship with a current client!

Each of the codes of ethics has rules about dual relationships. They all say no sexual relationships, but social work is even more strict. They say no physical touch if it would harm the client. 

The ACA says no sex until 5 years after terminating a client, but APA and AAMFT say 2 years. 

There are 3 guidelines to help us differentiate between dual role relationships and the rest of the chapter refers back to these:

1. Compatibility of expectations
2. Divergence of obligations
3. The power and prestige differential

Compatibility of Expectations

"As the difference between the expectations of the therapist and client increases, the potential for misunderstanding and harm increases"

• You need clear expectations about what the therapeutic relationship is! If your expectations are unclear, the client's will be even more unclear. 

Divergence of Obligations

"As the divergence between the obligations imposed by different roles increases, the potential for divided loyalties and loss of objectivity increases."

• For example, the roles of therapist and friend are generally divergent
• "Counselors who are tempted to enter a counseling relationship with a friend might do well to ask themselves whether they are willing to risk losing the friendship."

Power and Prestige Differential

"As the difference in power and prestige increases... the potential likewise increases for exploitation on the part of the therapist and an inability on the part of clients to remain objective about their own best interests."

• therapists often have considerable power over their clients even after termination
• This is where those intimate relationships come in. They typically do more harm than good for the client, even after the case has been terminated. 
• "Although few would suggest that therapeutic contracts ought to carry a lifelong obligation, it is equally implausible to suggest that the formal ending of a contract should entitle a therapist to engage in activities with a former client that will undo the benefits that therapy promoted."

Taking Appropriate Action

"When therapist client expectations are clearly defined and compatible, role obligations are convergent, and the power differential is small, there is much less danger that harm will ensue."

TECHNOLOGY

It can be used as a means of enhancing or exploiting therapeutic relationships

Technology in Information Management

"Identity information, standardized forms, diagnostic and treatment data, billing, progress notes, and archival records that create databases for therapy practices. 

We also transmit data electronically via fax, etc.

Technology as a practice resource

Sometimes we give our clients websites to look at, but make sure you're confident that ALL of the info on that site will be beneficial to the client's treatment. 

There's also a new thing called DIY Testing where people can answer questions about what they're going through and symptoms and they can give them a provisional diagnosis and advise them as to what paths of treatment they should take. While right now it's not super reliable, this could improve and become a great tool for us in the future!

• There's also technology-based supervision and consultation

Technology as a Therapeutic Modality

You can use email, skype, video chat, phone calls, etc. 

"Differences in process and outcomes among he three treatments were small and clinically promising"

Ethical Issues in the use of technology: Concerns for the ecology of therapy:

This could have a cultural problem... increase of efficiency and rapidity in communicating and work is great for westernized society, but what if that's repressive for some clients? 

Therapy is a process that often involves  patience and deliberation... but can technology undermine that?

If a therapist uses email as a primary means of therapy and communication this could be problematic if a client has an emergency/is suicidal and they can't get a hold of their therapist immediately. 

HIPPA laws come into place in order to regulate the electronic storage, receipt, and transmission of client data. 

The ethical principles of nonmaleficence, justice, and fidelity come in big time with this issue.

Electronic/Text Messages and Social Networks

This could make things sticky if you use too many means to communicate with your client- for example a therapist who tweets and emails and texts their client then the client gets the wrong idea about their relationship. When the therapist then puts an end to it, the client reports him/her for being unethical and confusing them about the parameters of the relationship.

HIV/AIDS, Confidentiality, Client Welfare, and Public Protection

The Tarasoff decision comes into play here big time! 

"A therapist is not to be encouraged routinely to reveal such threats since such disclosures could seriously disrupt the patient's relationship with the therapist and with the person threatened. On the contrary, the therapists obligations to the patient require that he [or she] do so discreetly and in a fashion that preserves the privacy of the patient to the fullest extent compatible with the prevention of a threatened danger."

So, basically... we need to take into account how in danger others are if our clients tell us they are HIV positive/have AIDS.

The danger must be FORESEEABLE before we can act on any information. So, if they are engaging in high risk behaviors and immediately endangering others, we need to do something.

"Jeopardizing the supportive nature of therapy for the client (and possibly others) must be a significant consideration in disclosure decisions.

Nonmaleficence is the preferred guideline for this scenario. 

"A therapist should not be encouraged routinely to reveal such threats... unless such disclosures are necessary to avert danger to others."

Research and Publication: Informing Ethical Practices

Practices that are not grounded in research can be the basis for nonmaleficence or, more important, harm for clients. 

"A practitioner who remains uninformed about a practice either through lack of interest or through bias agains alternatices may threaten beneficence, indulge referent power, and promote personal values at the expense of client care."

"Published research is a means by which therapists can (a) share information, (b) promote themselves, and (c) succeed in academia.