Course:PSYC537/2010WT1/Vignette6

VIGNETTE 6

You are a male psychologist in private practice working with a new client with severe depression and a history of abuse and neglect. You have assessed her suicide risk as moderate to high and have spent the last few sessions attempting to ameliorate that risk. In one of your sessions, she sits quite close to you and tells you that she daydreams about you holding her as she cries in session. She says that she feels embarrassed telling you this, but you’ve become her lifeline and she knows that you, of all people, will understand how great her need is for human contact. At that point she starts to tear up and cry quietly. What do you do?

STEP 1: Who are the people potentially affected by decision?

1. You (the psychologist)

2. The client described in the vignette

3. Your other clients (who may be affected if you and/or your practice were in jeopardy because what you decided to do in this situation)

4. Client’s loved ones (who may be affected if your decided course of action had a significant impact on the client’s suicide risk and/or level of depression)

5. Any students or supervisees under the psychologist (as they may look up to the psychologist as a mentor and exemplar) (SC)

STEP 2: What are the relevant ethical issues/laws? Which ethical values/laws are in conflict?

I think that the main ethical conflict in this vignette is between the therapist's desire to give the client the best therapeutic care (principle of responsible caring, not wanting to damage the therapeutic relationship by seeming to reject the client now that she is opening up to him, concern over the client's suicidality, etc.,), and the potential for the client to misinterpret the therapist's actions due to her attraction to him (which may have detrimental effects on the therapeutic relationship and possible legal consequences). I would imagine that it is especially important that the therapist in this situation be very aware of the power dynamic with this client, in light of her history. There is also the potential for sexual misconduct on the part of the therapist, but the vignette did not seem to indicate any reciprocal attraction, and I would imagine that the majority of therapists would not seriously consider engaging in sex acts with their clients. Below are relevant sections from the Code of Ethics and the Code of Conduct.

From the Code of Ethics:

Principle I: Respect for the Dignity of Persons

I.4 Abstain from all forms of harassment, including sexual harassment.

Principle II: Responsible Caring

II.1 Protect and promote the welfare of clients, research participants, employees, supervisees, students, trainees, colleagues, and others.

II.2 Avoid doing harm to clients, research participants, employees, supervisees, students, trainees, colleagues, and others.

II.10 Evaluate how their own experiences, attitudes, culture, beliefs, values, social context, individual differences, specific training, and stresses influence their interactions with others, and integrate this awareness into all efforts to benefit and not harm others.

II.17 Not carry out any scientific or professional activity unless the probable benefit is proportionately greater than the risk involved.

II.27 Be acutely aware of the power relationship in therapy and, therefore, not encourage or engage in sexual intimacy with therapy clients, neither during therapy, nor for that period of time following therapy during which the power relationship reasonably could be expected to influence the client's personal decision making.

From the Code of Conduct:

5.0 Preserving client welfare. In professional relationships, a registrant must take steps to protect or act in accordance with the client's welfare.

5.14 No harassment, exploitation, or sex. A registrant must not (a) engage in any verbal, or physical behaviour which is sexually seductive, demeaning, or harassing, (b) engage in sexual intercourse or other physical intimacies, or (c) enter into a potentially exploitative relationship with a client or former client to whom the registrant has at any time within the previous 24 months provided psychological services.

5.26 Avoiding harm. A registrant must take steps to avoid harming any individuals with whom he or she works or with whom he or she has a professional relationship (i.e. clients/patients, students, supervisees, research participants, organizational clients).

5.28 No sexual relationships. A registrant must not engage in sexual relationships with individuals over whom he or she has supervisory or evaluative influence or other authority - for example, students, supervisees, employees, research participants, and clients.

5.29 No sexual harassment. A registrant must not engage in the sexual harassment of any individuals with whom he or she works or with whom he or she has a professional relationship. (AH)

STEP 3: How do personal biases, stresses or self-interest affect my choice of action?

I truly feel for the female client in this vignette. My previous experiences working with individuals in a counseling context was working with women at a rape crisis center, and this presentation was, sadly, not uncommon. Adults who have suffered abuse and neglect as children often struggle with how to interact interpersonally with those around them, particularly survivors of child sexual abuse. Seeing how much pain and anguish individuals suffering with these issues must go through, I am biased towards wanting to give the client some comfort, perhaps by putting a hand on her shoulder while she cries. While this is my personal bias, I realize this situation changes significantly in the case that the client appears to be attracted to the therapist. I also realize that physical contact means different things to different clients; when I worked at the rape crisis center, we were always told not to touch clients, because, for some survivors, being touched when it was not expected can be extremely anxiety-provoking, and we felt it was better to be too conservative rather than too liberal on those issues. (SV)

I imagine that, in this particular case, I would also be swayed by the fact that the client is at a high risk of suicide. The fact that the client's safety is at risk could cloud my judgment on other ethical issues, with the focus solely on what the client would find most comforting in that moment (a hug, a hand on the shoulder) versus what might be best in the long term for boundary-setting with the client (no physical contact). My overarching bias is that any physical contact beyond those very limited examples (e.g., "holding her as she cries") sends a very strong conflicting message to the client about the therapist-client relationship, and I would not consider doing that, even though the client seemed very upset. Because of the inherent power imbalance in therapy, I think any potential physical contact of a more than cordial/friendly nature is improper. (SV)

Another potential issue that could play a role in this situation is if the psychologist finds himself attracted to the client. He may find he is drawn towards the option of providing the client with physical contact to comfort her because he wants to touch her not because this is the best care for the client. In this situation the psychologist may also be more resistant to the idea of letting the client know that ethically they can not engage in any sort of sexual relationship. (HM)

Your previous experience with suicidal clients may also influence how you act in this situation. For instance if you had a client who committed suicide in the past you may view your current client as being at a greater risk. As a result you may opt for comforting the client physically because you may be more afraid that they will take their life and you may be more desperate to try and do anything to stop this. Alternatively if you have had several clients who have presented as having a similar risk for suicide but who never made any attempts you may underestimate your client's risk of committing suicide and be less concerned about trying to prevent this. (HM)

STEP 4: Consult with colleagues.
Consult with colleagues or other psychologists who have extensive experiences working with clients who suffered severe abuse and neglect in the past. Depending on your levels of competence, experience and comfort working with these clients, consider the option of getting supervision from more experienced psychologists, especially on the issues (including potential benefits and risks) associated with physical contact in therapy. Also consider reading relevant professional literatures on this topic. In any case, properly document all consultation and decision-making processes and justify your actions after careful analyses of the risks to the client and therapeutic relationship, loss of objectivity, as well as steps to manage and minimize risks in your clinic note. <CC>

STEP 5: Develop alternative courses of action.
1. Hold the client while she cries.
2. Decline to hold the client but explain to her the potential harm to her and the therapeutic relationship as a result of such boundary violation.
3. Use alternative physical contacts that involve less intimacy (e.g., putting a hand on her shoulder). Explain clearly to the client that any physical contact carries no sexual suggestion and the sole purpose is to convey empathy and understanding in a strictly therapist-client relationship. (Depending on the client's level of emotional functioning, I would be very cautious about initiating any physical contact with clients who are seriously emotionally compromised)
4. Assess client's current level of suicidal risk. If the risk is clearly imminent and forseeable, and such risk can be significantly reduced by engaging in some form of physical contact with the client, it might be advisable to do so but within a reasonable limit (e.g., a gentle touch on the shoulder). Document and also explain clearly to the client the rationale underlying your decision (that you believed the touch improves therapetuic gain and is not exploitative in nature) when she poses a lesser risk of harming herself and is at an improved mental state to comprehend such decision. Also ask the client in later sessions how she feels about the situation, this is a good time to discuss and resolve her sexual attraction toward you that might result from your previous physical contact.

For all the above courses of action, it is extremely important to consult with your colleagues and properly document your reasoning of the action (weighing pros and cons based on a client-centered evaluation) and all decision-making processes. (CC)

STEP 6: Analyze likely short-term, ongoing and long term risks and benefits of each.

1. Following through with the client’s fantasy and holding her while she cries may improve or alleviate some of the client’s depressive mood in the moment. However, there is a high risk of the client misinterpreting this gesture inappropriately (especially given her attraction to you, and her history of abuse) and could feel confused. Further, despite her daydreaming of you holding her, you don’t know what her actual reaction to the contact would be (particularly with her history) and may turn out quite negatively (perhaps triggering a flashback to past events). The risk of harm is immense with this option, even if the harm may not appear immediately, it may show-up in the long-run.

2. This option sets very clear boundaries on the therapeutic relationship and avoids any confusion in that realm for the client. However, the client may feel rejected and inadequate or ashamed for telling you about her daydream, for even having the fantasy – and this is important as it potentially may worsening her suicide risk. Also, depending on the way this option would be carried out, the client may project from her previous experiences onto you and misread your response as neglectful, reinforcing psychological issues that have arisen from these experiences. The therapeutic alliance may be at risk here.

3. A small gesture may ameliorate the client’s mood through its empathic function. However, the client may or may not have the same understanding as you of the gesture and may get confused about the boundaries of the relationship (however, not as intensely as in option # 1). You may not get the response expected given her history. Depending on the way the explanation is carried out, it may convey sympathy instead of empathy, and the client may feel worse about her life (and thus increase suicide risk) as a consequence of perceiving others (you) as having pity on her.

4. Similar to option #3. (JK)

STEP 7: Choose course of action after conscientious application of principles.

The first thing is to enhance the use empathy in none physical contact ways, i.e., through nonverbal cues and a softer voice. This way whether you decide to initiate an appropriate level of physical contact or not, the client feels at ease in the warm environment you’ve created. I hesitate on the use of small physical gestures, because this would depend on how well you know the client (in foreseeing her reaction) and the history of the therapeutic relationship. One question to ask yourself is whether you’ve used small touching with this client before and if so, how did she reaction, how did that go. If touching has already been a part of the therapeutic relationship and it has gone well, I would stay consistent and perhaps lay a hand on her shoulder as she cries, or reach for a hand and give her a gentle squeeze.

The issue gets trickier if there is no history of touching in the therapeutic relationship, and you have a hard time gauging what her reaction would truly be. However, if in doubt, I would opt for no physical contact. I think it’s important here to remain consistent in the way you carry out the therapeutic relationship, as to not confuse the client and make clear as well that her self-disclosure doesn’t impact the relationship (i.e., giving the relationship a sense of stability). This is particularly the case if at the onset of the relationship, you have discussed together about the boundaries in therapy and have indicated then that no physical contact would be involved. However, the empathic and warm environment you’ll be amplifying should help avoid feelings of rejection or shame and avoid perceptions of neglect. Thus, suicide risk, at the very least, will not be increased, and at best, reduced.

Of course, when the client gets a grasp of herself (i.e., when the emotional moment subsides and the crying reduces), it would be important to explore the significance and emotions entwined in her daydream and to deal with the transference. (JK)

STEP 8: Act with commitment to assume responsibility for consequences.

STEP 9: Evaluate results of course of action.

STEP 10: Assume responsibility for consequences, including corrections or re-entry into decision making process if still unresolved.

STEP 11: Take action, as warranted, to prevent future occurrences.

The first step in avoiding this situation is being clear from the outset of therapy what constitutes the therapeutic relationship. In other words, be clear on what is and what is not acceptable behaviour, and which boundaries are not appropriate to be crossed. That way, if the issue comes up later in therapy, you can repeat what you initially told them and the client will better understand that they violated a rule.

At the same time, you don’t want to limit the client’s level of disclosure, especially because they are high risk. It is important to stress that the client will not be judged by disclosing any information. As a therapist, if a client does disclose information that threatens the boundaries of the therapeutic relationship, it is important to draw attention to the disclosure and to use that information to further help you and the client understand the client’s cognitions and why they think that way.

Finally, the client will learn what is and is not acceptable by the way the therapist interacts with them. If the therapist outlines at the beginning of therapy that it is not appropriate to have physical contact beyond a handshake, but then consistently rubs the client’s back when they cry and hugs them, the client will be confused as to what to expect of the therapist. The important thing in being proactive as a therapist is to model the actions that you outline are appropriate and not those that you have deemed inappropriate. By staying consistent, the client will have a clearer understanding of how they can interact with the therapist and what they should expect of them. (AA)