The Ethical Dilemmas No One Talks About


Remember when setting appropriate boundaries in psychotherapy was a no-brainer? “No” was the operative word--no gifts, no sex, no self-disclosure, no financial or social connection whatsoever outside the hermetically-sealed cloister of the consulting room. The rules were simple, direct, and unambiguous. But in today’s more informal therapy marketplace, the rules often don’t seem as clear anymore.


So what’s a therapist to do when a client anxiously offers a diamond-studded token of appreciation for all of the positive change you’ve helped him achieve? Do you accept a not-so-valuable gift--a tin of holiday cookies--from a vulnerable client to express thanks? What’s your decision when your therapeutic instincts conflict with the rulebook?

I highly recommend one article in particular--Ofer Zur’s “The Ethical Eye” is a refreshingly sane and practical discussion of how to reconcile risk management with humanistic values. You can read this article free or you can read it as part of our 3-CE Ethics Reading Course.

How does today’s culture make ethics more (or less) complicated in your practice? What resources do you consult in order to make the best possible therapeutic decisions?

Does communications technology--Skype, e-mailing, text messaging, Facebook, or even the telephone--pose any ethical issues to our therapeutic practice? Which modern ethical dilemmas would you like to hear more about--or are there any of your own that you’d be willing to share?

Rich Simon
Editor, Psychotherapy Networker

12.28.2010   Posted In: NETWORKER EXCHANGE   By Jordan Magaziner
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    • Not available avatar 12.28.2010 13:56
      I find that we are working in a field that is extremely rigid (at times) and that rigidity is being covered by "ethics." The example given by Ofer Zur in "The Ethical Eye" of a therapist being brought up on charges for offering what was essentially in vivo exposure treatment is perfect evidence of this (there was nothing unethical about what was being done, it simply wasn't psychoanalytic; does the logic go if it's strictly psychoanalytic, it is ethical and if it's not, then it's unethical?). Does the psychoanalytic method hold the monopoly on ethical practices? Is it the standard? And, if so, who says? Our field is changing dramatically and I find I can go to 20 different therapists of many different persuasions with the same ethical dilemma and, unless it's a very cut and dry issue such as direct sexual involvement, the answers are usually "It depends." Zur's article scared me to death. My goodness! I went to the home of a patient to meet with his mother for a collateral session because her abusive husband lived in my building! I did it out of regard for her fear of her ex-husband. It brought no harm to her, to her son, or to me, and allowed me to conduct a productive and helpful collateral session. I helped the patient. That's what I'm supposed to do. According to what I read in that article, I could have been charged with "unethical" behavior for making this home visit.

      If this is where the level of discussion is in psychotherapy, then we clearly have a long way to go in terms of "getting it." If being human and doing something out of concern for a patient rather than being rigid, coloring inside the lines, defensive, and protecting ourselves at the expense of our humanity and our patient's humanity is wrong, then I am wrong and I will be happy to be wrong.

      Many of the issues that Zur discusses -- and I agree with his assessment of these issues -- appear to be psychoanalytic nitpicking. What we should be concerned about is truly unethical people who do take advantage of patients (i.e., take advantage of them sexually, steal their money, manipulate them for the therapist's own personal gain, etc.), not someone who takes a tin of cookies as a holiday gift. This lunacy is what, at times, makes therapists look like fools to the layperson and does a disservice to our profession.
    • Not available avatar 12.28.2010 17:27
    • Not available avatar 12.28.2010 18:25
      The Hippocratic oath of "do no harm" and copyright rule of "no financial gain" seem to me to be acceptable ethics guidelines also. In the editorial example:plate of cookies "does no harm" and provides no financial gain...while a diamond "does harm" to someone's bank account and "provides gain" to another's... which to me constructs an ethics problem. I HAVE NOTICED THAT SOME CHIROPRACTORS HAVE THE ABILITY TO TREAT A CLIENT AND SOLVE A PROBLEM QUICKLY BUT PREFER TO SELL TREATMENT PROGRAMS WHICH REQUIRE CONTINUAL VISITS AND PAYMENTS...AND I FIND AN UNSPOKEN ETHICAL ISSUE IS PRESENT AMONG SOME THERAPISTS WHOSE INCOME IS DEPENDENT UPON MISERY OF CLIENTS AND FREQUENT SESSIONS, INSTEAD OF ESTABLISHING AND REACHING TERMINAL OBJECTIVES.
    • 0 avatar Linda Thomas 12.29.2010 01:32
      Twenty years ago I saw a client who fell in love with me. His expression of this love was the same action he had felt compelled to use to try to keep his former wife from leaving him: he bought her a fur coat, then a new car, then a swimming pool.

      She in fact did leave him at the peak of a depression caused by severe physical injury on the job, rendering him disabled. I shepherded him through many hospitalizations and recovery to the point where he was able to regain his hope for a better life and a return to physical activity.
      He was a truly delightful gentleman and on a personal level, I found him to be rather exciting (my counter transference) since he was the Santa Claus I’d never known in my young life.

      However, I held on to my clinical/ethical/sane/ known self and sacrificed my momentary, yet powerfully compelling, desire to discontinue therapy and/or accept the gift he offered. It shocked me how much this required of me, this wild ride on the therapy boat, steering it through rapids. I dragged into the therapy issues of need, power, and love. Both of us found it difficult to admit culpability, but if there was ever was a chicken or egg question, it was clear that the reason for his coming to see me never did include looking for a wife in the yellow pages of therapists.

      What was the gift? Deprived of asking me to marry him, my client told me he’d visited his attorney and arranged to leave his (considerable) acreage and home – yes, to me - in his will! I told him I can’t accept it – pure and simple. I love my work, I told him, and I don’t want to lose my license. He told me his attorney told him this happens all the time and it’s fine– it was a gift of gratitude for my services, etc. I was still hooked on “being given to” and it took all my strength to say no again and again.

      In the weeks that followed, all documented, we slugged through a number of painful issues with more candor than I knew I had in me - his need for control, his lack of belief that he is a lovable human being without having to prove anything, his unwillingness to take no for an answer and the resultant lack of authentic connection, my appreciation for his generous spirit and, yes, for him, and finally the goal of all therapy and transferences of love and need – the joy of knowing and feeling your human heart. His job was to take that inside himself and be open to new life outside of our work together, for it would surely happen, I told him.

      He was wounded, but realistic about what therapy can and cannot be. This, of course, opened the door to growth.

      During this time, I consulted with colleagues. Some of them joked, does he have a brother? But, I never would have taken this to a risk management/ethics conference, which usually creates and feeds paranoia with a focus on harm and pathology. I think I speak for a number of us who did not come into this field for those purposes. I completely agree with and applaud Dr. Zur’s writing that this healing work we do cannot be held to rigid, fear-based applications of “rules” that keep us away our humanity.
    • 0 avatar Michael Michnya 12.30.2010 13:27
      Ethics have never been a simple matter - if they were, the various professions wouldn't developed codes of ethics - and our multicultural society has made it even murkier. And because it's impossible to anticipate every possible scenario, rules can only serve to guide us. So, no matter how much risk management people and malpractice insurers want to reduce exposure to successful lawsuits (understandably because it will cost them money), there probably is no "safe" practice. I believe that we must continue to give our clients the best, most effective service that we can - whatever the particular discipline or modality of treatment - and that if we do so in good faith, with their best interests at heart, we will be practicing ethically.

      That said, I heartily concur with Zur's suggestion to document our work thoroughly and contemporaneously as the primary measure of self-protection. However, I disagree with the commentator above who noted "no financial gain" as an acceptable ethical principle for therapists. It might be appropriate for prients or monks who have taken a vow of poverty and depend upon the charity of others for their daily bread, but as for those of us who do this work for a living, a reasonable financial gain is fair payment for services rendered. As for the example cited, how harmful the gift is all depends upon the circumstances of the giver: taking the plate of cookies from someone who doesn't have anything else to eat may be far more harmful than accepting the diamond from the obscenely wealthy, however they earned their money.
    • Not available avatar 01.01.2011 07:55
      Two years ago I moved to a small town and ran into an interesting ethical delemma that I still have not resolved. As the only EMDR approved consultant in my area, I was offering a consultation group for therapists trained in EMDR. Several of the therapists dropped out because they had concerns about the ethics of another participant. Unfortunately they did not feel comfortable confronting the person, which put me in the position of having to confront her and ask her to leave the group based on hear-say, which I was not comfortable doing. I have concerns about the reported poor ethics of the therapist. I also have a need to improve the practice of EMDR with consultation for the local community of clinicians. My temporary but unsatisfactory response was to suspend the group, out of my own ethical concerns (and since the participation had dropped). I still haven't figured out how to resolve the problem. Open to suggestions...
    • Not available avatar 01.04.2011 15:45
      I believe that the concerned therapists had a responsibility to address this issue rather than bowing out of their commitment to attend the consultation group. If they refused to do so I would have approached the therapist about whom allegations were being made, expressed the concern, and invited her to address the group. Another option would be to invite all the original participants back, with the first topic being one that may (at least indirectly) address the concern. I strongly feel that not to act in a constructive manner to get this concern into the open is, in itself, unethical.
      • Not available avatar 01.09.2011 13:09
        Just to note--the last comment wasn't a response to the article, but to the previous post from the EMDR consultant who ended with "open to suggestions".
    • 0 avatar James Lein 01.05.2011 03:20
      Well, we do accept fees. In fact, this is a reason I worked mainly in the public sector. It didn't seem right that I was only seeing the clients who could pay or had insurance. I've also worked part time in private practice but always in a clinic where someone else handled the fees and collections. I've never done the pay me as we go system. This seems very much like receiving gifts, and could be confusing for clients. They're putting money in our hands; why not cookies? Or maybe the answer is to discount the fee if gifts our given, perhaps being paid by some clients in live chickens, as some old family docs were once paid.
    • Not available avatar Kathy Hardie-Williams 10.16.2011 22:56
      Hi Rich....I am doing a project for a class I'm taking. I'm a practicing marriage and family therapist. The project I have taken on for my class is the idea of a network for therapists as a venue for self care. This network would only be available to therapists. So often, therapists don't implement self care into their lives at the level they need to given they type of work they do. Although ideally, therapists should always been participating actively in therapy, I'm sure many don't; where do therapists turn for support when they need it? I was wondering what your thoughts on this are. I've been doing some research, and while there are 'networks for therapists' that exist for marketing purposes and for the purpose of providing professional resources, I haven't found one where the objective is to provide a venue for self care for other therapists.
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