Course:PSYC537/2010WT1/Vignette8

VIGNETTE 8

You have been seeing a client who was referred for treatment by his workplace. He is currently on long-term disability due to chronic pain, depression, and bulimia. His employee benefits will fund 6 sessions of treatment, but you have already seen the client for 4 sessions and little progress has been made. You believe that you can help this client, but progress is slowed both by the client’s resistance to therapy and by his complex set of problems. What would you do?

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

1) the client

2) you

3) the employer (who is responsible for funding the benefits plan)

4) the client's co-wokers

5) the client's family, friends, and significant other (AA)

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

Charging fees that are fair for your time, energy, knowledge and value of the service. Improving access to services, regardless of charge, at a societal level – including doing your part to offer some service at little or no charge. Assist the client in finding a way to receive services when third party payers don’t cover fees and the client can’t afford it.

Promoting the welfare of the client, seeking the best possible service for him. Offer activities for which competence is established. Take steps to refer a client when it becomes clear that the client’s problems and needs are beyond your own competence. Take steps in the psychotherapy process to improve change when progress is at a stand still, whether that means modifying the approach or referring out. (JK)

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

1. Your (the therapist’s) financial situation can bias your decision as to whether you will be willing to offer sessions at a lower rate or for free after the client has used up his 6 funded sessions. You will be more likely to offer these services at a lower cost if you are financially secure or wealthy.

2. How much you like to client on a personal level can also affect your decision to offer free or discounted psychological services.

3. Your perception of the availability of low-cost practitioners in the area can also influence this decision. If you think the choices are scarce, you may be more likely to continue seeing the client yourself.

4. Since this is a new client (you have seen him for only 4 sessions), your current caseload may also bias your decision to take him on after his 6 funded sessions. If you already have a demanding caseload, you may be reluctant to take on more clients as this may increase your chance of burning out and decrease your competency in the long-run.

5. How fair you deem these workplace mental health benefits are can also affect your decision. If you think 6 funded sessions seems like a reasonable number for this client, then you may be less inclined to help the client beyond these 6 sessions. However, if you believe that the client’s workplace should have granted him more than 6 funded sessions for his complex problems in the first place, you may be more likely to lobby for more session on behalf of your client.

6. How common you think practitioners offer sessions at a lower rate or for free to financially disadvantaged clients can also influence your decision. If you think this practice is the norm, then you may be more likely to do so yourself. (SC)

STEP 4: Consult with colleagues.

STEP 5: Develop alternative courses of action.
Option 1: Continue seeing the client to the end of his six sessions, and then terminate.

Option 2: Refer him to another practitioner who specializes in these issues, perhaps one who is low cost or sliding scale to allow more sessions to deal with his issues. Bridge the therapeutic gap with the client in the interim until the other practitioner is available, if necessary.

Option 3: Discuss the client's resistance to therapy with him, and attempt to come to an agreement that would allow you to keep seeing the client past the end of the six funded sessions (perhaps by providing them at lower cost).

Option 4: With the client's permission, petition the employee benefits agency to get funding for more sessions. Continue therapy with the client, discussing his resistance to treatment. (SV)

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

1. Risks: his problems may not get any better without therapy, he may be unable to go back to work if he continues to experience chronic pain, depression, and bulimia. Benefits: The client wont have to pay for any services, you aren't treating a client who is not making progress.

2. Risks: Another practitioner may not be able to help either if he remains resistant, he may end up paying for services that don't help him, he may find it difficult to cover the expense of your services while you are bridging the gap in services. Benefits: allows him to get help in a more affordable way, he may get better and be able to work again.

3. Risks: may be unfair to your other clients who are paying the full amount, may be difficult financially for yourself, he may continue to not make progress. Benefits: He doesn't need to start from scratch and build a new therapeutic relationship, he is able to get help.

4. Risks: He may continue not to make progress, the employee benefits agency may refuse to fund more sessions. Benefits: he may continue to get treatment without having to pay for it and without affecting the therapists financial situation. (HM)

STEP 7: Choose course of action after conscientious application of principles. This is a complex problem that depends on several factors. Most importantly, is the client's resistance something that you truly and objectively believe can be overcome by you or any therapist, as well as what options you can come up with in terms of funding (either finding a lower cost therapist that would be able to handle his complex situation, or finding more funding from his employer). Furthermore, even if the resistance can be overcome, it sounds like his problems are too complex to be realistically tackled in a short amount of time (if you were to continue treating him yourself and spill over into lower cost sessions, this may go on for much longer than anticipated).

It will be important to approach your client with the issues of his progress in therapy thus far and the number of sessions he has left that are being paid for. Particularly if you are referring out, he needs to know why. Why do you think he is resistant? Is it related to his problems? Is it because he doesn't want to be in therapy (and was sent there by his employer)? I think I would first approach these issues with the client because it will be important for future therapy.

I think the most important course of action for this client will be to continue therapy to work on his complex set of issues. Because of the issue of money, I think I would work on finding him a low-cost situation where he can afford having long-term treatment. This may require you to provide a couple of sessions at lower/no cost to firstly address some of these issues as well as to bridge sessions to the new therapist to ensure continuity of care. (KA)

I would also consider getting the patient involved in writing to the employee benefits agency the potential adverse consequences to the patient, if the treatment is discontinued after 6 sessions, as well as a detailed treatment plan tailored to the client's presenting problems. Based on what I have learned about the patient, I would also identify the issue(s) (e.g., depression, chronic pain, or bulimia) that pose(s) the greatest challenge for the patient and causes the greatest interference with his capacity to work. For instance, if the patient’s depression seems to a result of chronic pain, I will consider referring him to a chronic pain clinic for treatment, perhaps at a much affordable cost. The bottom line is that if the psychologist has reasons to believe that the employee benefits agency's authorization for treatment is less than appropriate care, we should consider referral and/or petition to his employee benefits agency for more funding for treatment. (CC)

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.

When first assessing an individual to decide whether or not to take them on as a client, it would be important to find out how many sessions the individual's insurance will cover. If the psychologist knows that the insurance will only cover a small amount of sessions and the client is unable or unwilling to pay for more sessions, they should seriously consider whether this is enough time to sufficiently treat the potential client. (In this case I would imagine that an individual presenting with two mental health issues and an underlying chronic physical health issue would be too complex to treat effectively in six sessions.) Rather than allowing many sessions to elapse before thinking about the potential financial problem, the psychologist should bring it up with the client as soon as it is discovered, so that there is enough time to go through options with the client. The client will then be able to decide whether they would like to be referred to a low-cost service, or whether they will be able to save enough money to pay for subsequent sessions, or whether they would like to increase the length of time between sessions and do more work on their own. The psychologist also has time to consider whether or not they are able to provide low-cost/no-cost service themselves, or to get the client on a wait-list immediately for a lower-cost service, and also to petition the insurance company for more sessions before the end of the coverage is imminent. From that first session onward, the client will then be better prepared for the end of the insurance coverage, and may feel more secure knowing that there is a plan in place already. (AH)