BLENDED FAMILY DILEMMAS

Facing Stepparent Dilemmas with Blended Families

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Free Shipping All orders of Don't have an account? Update your profile Let us wish you a happy birthday! Make sure to buy your groceries and daily needs Buy Now. Let us wish you a happy birthday! Adult family members will also often have secrets from each other.

These may range from the trivial to the highly significant. The therapist should consider how they will handle the disclosure of secrets should one family member choose to do so directly to the therapist out of earshot of the others e. The best strategy will involve planning for such eventualities in advance. The most reasonable way to handle this matter ethically would involve formulating a policy based on therapeutic goals and defining that policy to all concerned at the outset of treatment.

Some therapists may state at the beginning of therapy that they will keep no secrets. Others may express some willingness to accept information shared in confidence to help the person offering it determine whether it is appropriate for discussion in the whole group. Still another option would involve discussing the resistance to sharing the information with the member in question. That approach might help the person to share the information with the family, if indicated. The therapist who fails to consider and discuss these matters in advance with family clients may make accidental disclosures within a very short time that could have serious ethical fallout.

To whom does one owe professional obligations when treating a family or a couple? Does a psychotherapist-client relationship exist when a parent participates in services only or chiefly to aid the child? What duties apply when a family member or the partner of a client comes into the therapy or evaluation session for the purpose of assisting in the care or evaluation of the primary or identified client? The answers to these questions depend on the context, but our ethical codes require that we clarify the situation and obligations with all parties at the outset of the professional relationship APA: The short answer to the questions posed above requires that we recognize a duty of professionalism, respect, and care to all those who consult with us.

However, the specifics of the obligations differ as a function of the particular roles we hold and how we help clients understand these different roles. When a couple arrives seeking treatment, our duties to both parties are equal. Similarly, when we agree to treat a family, we owe similar obligations to all those participating in the sessions. However, when one party has status as the identified client, our primary obligation will focus on that individual.

Consider the following situations. Fuss wondered whether Dr. Lastic could see the two of them together to help improve their relationship. Lastic agreed to see them, but matters soon worsened. Fuss had expected Dr. Lastic to take her side, and get Mr. Snice to behave differently. Snice brought up many ongoing issues of his own that he had hoped to get help with, including chronic problems with anger management and alcohol dependence.

Billy Go, age 6, had begun treatment with Wyatt B. Hoovesya, LPC for oppositional behaviors at home and school. Hoovesya saw Billy weekly for 40 minutes, spending another ten minutes with his mother, Frieda Go, offering parental behavior management guidance. At the end of the fourth session with Billy, Mrs. Go comes into the office and begins to sob. She has reached her limit in coping with a number of life stresses and is having passive suicidal ideation.

Hoovesya to help her cope. In both of these cases the therapists encountered unpleasant surprises that they might have taken steps to prevent. Lastic had no inkling of Mr. Lastic had intended to switch from individual to couples therapy, she should first have thoroughly discussed the role change, expectations and potential consequences with Ms. If her intent was to only to briefly include Mr. Snice as a collateral participant to assist Ms. Fuss in her treatment, that role should first have been clarified with Mr.

Snice, who seems in need of his own individual therapist. With respect to the Go family, Mr. Hoovesya may have explained to Mrs. Go at the beginning of treatment that his focus was on Billy and that his meetings with her were merely for parental guidance. When she presents as clearly needing treatment of her own with some urgency, Mr.

Hoovesya finds himself needing to do some emergency triage and referral with a woman who may believe she is already in therapy with him.

Facing Stepparent Dilemmas, June Hunt

When dealing with any kind of collateral clients, ethically sensitive therapists grasp the importance of clarifying their role and establishing the boundaries of a professional contract at the start of the interaction. Such participants in therapeutic activities also need to understand that information provided in such contexts is confidential, but may not be privileged. Another important issue involves avoiding potentially detrimental boundary crossings with individuals known to be close relatives, guardians or significant others of current clients e.

Terminating therapy for the purpose of circumventing this policy would also qualify as highly inappropriate. As noted earlier, the ethics codes of professional associations and a number of state and federal laws now make it clear that the therapist must begin obtaining informed consent at the start of a professional relationship APA: Clients may need reminders or updates as the professional relationship progresses. This forms the heart of a therapeutic contract with the couple or family.

One can only give consent for oneself, and doing so implies a competent, knowing, voluntary act. That means the person giving consent must have the legal and mental competence to consent, have access to the information they need in an understandable format, and make the decision on a voluntary basis. This is sometimes referred to as proxy consent. In some cases, the incompetent individual is also asked for assent, meaning that they may veto their own participation. Thus, parents may insist that their reluctant minor child participate in family therapy.

What about the situation in which the goals and values of the family, identified client and therapist are not completely aligned? Issues related to abortion choice, sexual preferences, religion, and family values are among the potential conflict areas. The therapist must assume responsibility for avoiding the imposition of personal values on the client while striving to optimize quality of care.

Arnold Polite, age 14, is referred to Frank Facilit, Psy. Facilit finds Arnold to be somewhat inhibited by the close, and at times intrusive, ministrations of his parents while Arnold struggles to develop a sense of adolescent autonomy. Over several months, Facilit sees good progress in his work with Arnold, but then he begins to get telephone calls from Mr. Polite, who express concern that Arnold is becoming too assertive and too interested in people and activities apart from the family.

In this instance, the progress of the client toward more developmentally appropriate behavior alters his relationship with his parents, and they may not care for the new behavior. As we discuss in this section, the best interests of one client may well be antithetical to the best interests of a co-client or close family members.

Facilit can work toward some accommodation by means of a family conference or similar collaborative approach, but the possibility exists that this will not prove satisfactory. Although a small number of states e. If a child wishes to refuse treatment authorized by a parent, there will most likely be no legal recourse, even if the proposed treatment involves inpatient confinement Koocher, ; Weithorn, ; Weithorn, Some mental health professionals have argued that the best interests of parents are not necessarily those of children, and that mental health professionals are not always able to function in the idealized unbiased third-party role imagined by the court Koocher, ; Weithorn, ; Weithorn, Jackie was seen by Amos Goodheart, Ph.

Goodheart discusses his options with Jackie, explaining that he cannot offer treatment to anyone under 18 years of age without parental consent. Goodheart recognized two important legal obligations and an additional ethical obligation. Second, he recognized his obligation to report the case to authorities duly constituted to handle child abuse complaints. This is a statutory obligation in all states, although it certainly would have been less than professionally responsible had he sent Jackie home to additional potential abuse and done nothing.

Jack Fury was an angry year-old referred to Harold Packing, M. After the fourth session, while Dr. Packing was in an appointment with the next client, they smelled smoke and discovered that a fire had been set in the waiting room. The fire was put out, and Dr.

Packing called Jack and his parents in for a meeting. Jack acknowledged setting the fire. Whereas some therapists might have agreed to continue working with Jack, Dr. Packing recognized these feelings and dealt with them promptly. Psychotherapists have no ethical obligation to continue treating clients when threatened or otherwise endangered by that client or another person with whom the client has a relationship APA: After all, one can hardly devote full professional attention to such clients with threats or danger looming.

In general, the therapist should assume responsibility to provide clients with the information they need to make their own decisions about therapy. The therapist should be willing to treat each client as any consumer of services has a right to expect. Although many therapists do not use written contracts, some therapists and clients do agree to highly structured written documents outlining their relationship in great detail, particularly in certain legal e. As the cases described earlier illustrate, it is very easy for people involved in couple or family therapy to misunderstand or become confused about various roles and obligations.

We summarize the essential elements of any client-therapist treatment agreement in Text Box 1 from the perspective of the questions clients may have in mind. Couple and family therapists should focus on the nuances that having more than one participant in the unit of treatment might involve. Who is my client e. What special issues apply when working with a couple or family with minor children What goals will we work toward? How will the process of therapy go forward? How will we work together? When and how often will we meet? How can we remain in contact between sessions, when necessary?

How do I relate to clients or not via social media? Explain what client s and therapist can expect regarding: The process of therapy. Any risks that may accompany treatment. Fees, methods of payment, and services covered by third-party payments or not. Treatment techniques to be used. Therapist availability and communication modes, including any that the therapist will not use e. What are the limits of confidentiality outside of our professional relationship and across the unit of treatment couple or family? What professional records will I keep and will I segregate them by person or keep a single family-based record?

What state or federal laws govern access to the records? What are my personal policies for record management and releases within the statutory options available to me? How do laws or record release policies bear on minors or incompetent clients? This circumstance may result from loss of a job, divorce, or other abrupt financial disaster. At times, however, such adults have not made the transition to implementing adult responsibilities, such as working to support themselves.

They fear that Nora lacks the skills necessary to function independently and establish herself as an independent adult. She seems depressed and in a constant state of tension with them at home. They approach Sara Solver, M. Even though the parents are willing to pay for professional services, Nora must consent on her own to participate and to the goals of treatment. The parents may pressure Nora to attend sessions, but the therapist has an ethical obligation to enable Nora to express her wishes and preferences.

The need for a special focus on the limits of confidentiality follows later in this course. Clients might also reasonably expect warnings about other foreseeable as well as unforeseen effects of treatment. Obviously, no therapist can anticipate every potential indirect effect, but a client who presents with marital complaints, for example, might change behavior or make decisions that could drastically alter the dynamics of the relationship for better or worse. Likewise, a client who presents with job-related complaints might choose to change employment as a result of therapy.

Such cautions seem particularly warranted when the client has many inadequately addressed issues and the therapist suspects that uncovering these concerns e. Consider the married adult who enters individual psychotherapy hoping to overcome individual and interpersonal problems and to enhance the marriage.

What if the result leads to a decision by one partner to dissolve the marriage? Tanya Wifely enters psychotherapy with Nina Peutic, L. As treatment progresses, Ms. Wifely becomes more self-assured, less depressed, and more active in initiating sexual activity at home. Her husband feels ambivalent regarding the changes and the increased sense of autonomy he sees in his wife. He begins to believe that she is observing and evaluating him during sexual relations, which leads him to become uncomfortable and increasingly frustrated.

He begins to pressure his wife to terminate therapy and complains to an ethics committee when she instead decides to separate from him. Wifely experiences the change as one for the better. She certainly has the right to choose to separate from her spouse and continue in treatment. On the basis of these facts, we cannot conclude that Ms. Peutic did anything unethical. However, we do not know whether Ms. Peutic ever informed Ms. We must wonder whether the outcome might have been different had Ms. Wifely that changes could occur in the marriage as a result of her individual therapy.

Wifely and her husband had initially sought Ms. However, in some instances couples counseling leads to outcomes where one partner wants to stay in the relationship, and the other believes it best to end the relationship. It will be important for us to review progress and goals as our work progresses, but I did want to caution you that sometimes couples do diverge in their thinking over the course of therapy.

In general terms, the parents or guardian of a minor child can authorize treatment of that child individually or in a family context. The most common ethical challenges occur when parental authority is split because of separation or divorce. In some instances, one parent may support treatment, but the other may object. In the context of family treatment, such objections often co-occur with visitation disruptions, behavior that may tend to estrange or alienate a parent, or the remarriage of a parent with resulting blended family concerns. In any such instances, the therapist should take care to confirm the applicability of state laws and the statements made by either parent about their authority.

When parents have joint or shared legal custody, either parent may generally grant permission for medical or psychotherapeutic care, particularly in an emergency, unless court decrees state otherwise. Similarly, either parent with joint or shared custody can demand an end to therapy of a minor child. Resisting parental demands to cease treatment could result in disciplinary actions by licensing boards. In general, the best practice would be to get permission to treat from both parents, even if only one has requested treatment and the other will not be participating e.

Some circumstances may not lend themselves to seeking permission from one of the parents, even though their parental rights have not been terminated. Suppose that one parent claims to be a victim of domestic violence and is residing in a confidential shelter with her child. Consider the situation in which one parent is incarcerated at a distant facility. In these situations, seeking permission from the parent not bringing the child to treatment may be contraindicated.

When a parent is unavailable for purposes of consent or when parental contact might reasonably be expected to harm the child:. All of the normal professional and legal standards that apply to the confidentiality of mental health services and records of individuals also apply to couples and families. However, some special considerations flow from situations in which the unit of treatment involves two or more people.

Therapists should take care to establish rules about disclosure of information across the family. This becomes especially important if the therapist will have individual meetings with family members or will accept phone calls or messages from one member. The practitioner should also keep a record of which materials were sent, to whom, and when.

Clinical records should bear a confidential designation, and the recipient should remain aware of any limitations on their use. One should also exercise caution to see that only material appropriate to the need is sent. The evaluation included taking a developmental and family history, meeting with both parents, reviewing school progress reports, and administering cognitive and personality tests. He recommended appropriate psychotherapeutic intervention, and the family followed through. Several weeks later, Dr.

At the same time, Dr. When the client is a child or deemed legally incompetent, parents or guardians generally have full legal entitlement to record access. From the outset of any such relationship, all parties should receive information about the specific nature of the confidential relationship. A discussion about what sorts of information might be shared and with whom should be raised early.

Challenges of Blended and Step “Remarried” Families

This is not a difficult or burdensome process when done as a routine practice. Max was referred for treatment because of secondary enuresis and acting-out behaviors of recent onset. The birth of a new sibling in the Bashem family several weeks ago seems to have contributed to the problem. Near the end of the fifth therapy session, Max expresses some anger about his new sibling and tells Dr.

Donna Rhea, age 14, also sees Carla Childs, Psy. Donna feels alienated from her parents and is sexually active. They demanded a full briefing from Dr. Childs, threatening to pull their daughter out of treatment. They also threatened to file an ethics complaint. These two cases illustrate some difficult, but not insoluble, problems.

In the case of Max, Dr. Does Max have a history of violence toward others? Has he exaggerated his anger in the context of therapy for emphasis? Childs will want to explore this issue with Max before ending the session, but suppose she does feel that he poses some risk to the sibling? Suppose that Max cannot commit himself to leave the baby unharmed in the coming week between sessions. Childs could express her concern and discuss with Max the need to help keep him from doing something he might later regret.

She could talk with him about alternatives and explore a variety of them, one involving a family conference in which Max could be encouraged to share some of his angry feelings more directly. If all else fails and Childs believes that she cannot otherwise stop Max from hurting his sibling, she must discuss the matter with his parents as a duty-to-protect issue. Not to do so would constitute malpractice. While such a circumstance would be rare indeed, Childs should certainly discuss the need to violate the confidence for his ultimate benefit.

The parents may feel jealous of the trust and respect their daughter seems to have in the psychotherapist, while feeling angry and disappointed at her sexual activity and resulting infection. A conference does not seem inappropriate, but would probably best succeed as a family meeting with Donna present.

Childs could attempt to retain a supportive and therapeutic stance in such a session without necessarily breaking confidence. The sort of information the parents expect seems unclear. An outright refusal to meet with the parents in this circumstance would not serve the interests of any of the parties. Many state laws do permit minors to obtain treatment for sexually transmitted diseases or birth control information without parental consent and in confidence.

A preventive step might have included a pre-treatment family conference with a discussion of the psychotherapy relationship and any attendant limitations. At such an initial meeting with both the parents and adolescent present, the therapist might begin by asking each person to describe their concerns. How do all of you feel about respecting such confidentiality?

Access to records sought by family members of an adult should generally be denied unless some special reason justifies considering the request. Special reasons might include the imminent-danger test or the legally adjudicated incapacity of the client. Marla Noma lived with cancer for many years, and during that period she occasionally consulted Michael Tact, M. During a surgical procedure, Marla became comatose and remained alive on life support equipment, although with little chance of recovery.

In such a case, when the client cannot speak for herself, it probably would not be unethical for Tact to respond openly to a duly authorized request for information from the next of kin. The surviving line of consent generally recognized by courts is as follows: First in line to grant consent is the spouse even if living apart from the client, as long as they are not divorced. Second are the children of legal age, with each such child having an equal voice. Next are parents or grandparents, followed by siblings, each also having equal voice.

If none of the above survive, courts will occasionally designate the next-nearest relative or closest friend. Both declared the mutual commitment to improving their relationships in response to Mr. After some weeks of treatment, an impasse in the work seems evident, so Mr. Cornered decides to have one individual session each with Ury and Ima.

In his meeting with Mr. Hydin has shown us a very different type of problem that we alluded to early under the heading of family secrets. His extramarital sexual activity runs counter to his outwardly stated shared goal in therapy and he appears to expect that Mr. Cornered will not reveal this to his wife. Cornered finds himself on the spot, because it seems he may not have clarified a cross-couple confidentiality policy. If he keeps Mr. He wishes that he had clarified his stance on keeping unilateral secrets in advance.

Many therapists will not agree to keep secrets within a couple or family unit and some will not agree to individual meetings for just such reasons. Legislative bodies across the United States have enacted statutes that require members of certain professions serving vulnerable persons to follow regulations requiring protective breaches of confidentiality. The authority for such doctrines flows from the legal principle of parens patriae. Under that doctrine, the state must act in a parentalistic role as the guardian or protector of the incompetent.

The state may also use its police powers and courts to act as protector by intervening in families or forcibly confining people who pose a danger to themselves or others with protective mandates. In some circumstances, the law specifically dictates a duty to notify certain public authorities of information that might be acquired in the context of a therapist—client relationship. The general rationale on which such laws are predicated holds that certain individual rights must give way to the greater good of society or to the rights of a more vulnerable individual e.

Other protected populations may include elders, disabled, or otherwise dependent individuals. Statutes in some states address the waiver of privilege in cases of clients exposed to criminal activity either as the perpetrator, victim or third party. Shootings in schools and other public venues by troubled individuals have triggered considerable public concern, and have led to a number of legislative efforts to use mental health professionals as a kind of early warning system.

While not strictly speaking a couple or family issue, presence of such weapons in the home or instability of a firearm owner may be disclosed by a family member against the wishes of the owner. As with many of the topics covered in this course, therapists should stay current on the laws in their practice jurisdictions.

Dangerousness or hazards requiring a mandated report can certainly come to light in the context of couple and family therapy. However, another common problem involves the matter of how records are kept in multiple client therapies. When treating a couple, should you keep a single record for the couple? How about when treating a family?

Do you keep a single family record, or put everything in the file of a single identified client? What do you do with notes if you have an individual session with one member of the couple or family? We recommend keeping files distinct in a manner that reflects who was present. This can become important later if someone seeks to authorize the release of the records. In the case of a couple, the record could be released to either of the people who were present as patients in the session. They were both parties to what went on. However, if an individual client brings a collateral party into their session, the collateral should have a right to only those session notes for which they were a participant.

If a family member has an individual session, those individual session notes should not be comingled with records of sessions that involved the whole family. Cases involving alleged abuse or custody disputes can prove very messy with respect to requests for records in court and other contexts, and the likelihood of those issues arising is not always clear at the outset of treatment.

Clinical psychologist Polly Rost learned the hard way about the importance of consulting an attorney in response to a subpoena for records. The Pennsylvania Board of Psychology issued a formal reprimand to Rost for failing to seek legal advice in dealing with a subpoena. The parents of a child client sued the York Jewish Community Center because their child suffered headaches after a fall there. After receiving a complaint from the parents, the Pennsylvania licensing board ruled that Rost should have sought the advice of counsel before releasing records in response to the subpoena, and the courts upheld that ruling Rost v.

Pennsylvania Board of Psychology, In , Diana Kohl, a licensed marriage and family therapist, was called to testify in Steuben County NY family court regarding a child custody case. Both the father and his 3-year-old child had participated in court-ordered therapy sessions with her. The law guardian representing the child asked that Kohl provide all case notes from those sessions. My ethics say I am not to do that…I take lots of fragmented notes. They would not be helpful to the lawyer. There are only two exceptions to confidentiality — only if I have knowledge of child abuse, or if someone is actively suicidal or homicidal can I breech confidentiality.

Kohl, Judge Joseph Latham disagreed and signed a contempt-of-court order. A few months later, following a routine traffic stop, Ms. Kohl found herself under arrest in handcuffs. Kohl ultimately gave her notes directly to Latham to review.

Both Rost and Kohl had their own ideas about how handle the requests for records they received, and both were simply wrong. When dealing with the legal system, getting sound advice from an attorney may prove the wisest course of action. When appropriate to release original materials from your case files, offer an authenticated notarized copy rather than the originals.

If the court specifies that you must provide the originals, be certain to retain a notarized copy of the records for yourself or have your attorney do so. Important documents can easily become lost or misplaced as they travel through the legal system. Silent was subpoenaed to appear before a grand jury and was questioned about the content of his sessions with the Abusers. Silent asked for a judicial determination on privilege. He noted that, as a legally mandated reporter of suspected child abuse, he would have made an official report had he suspected anything.

A judge ruled that the prosecutors should have adequate latitude to investigate, and because the case involved alleged child abuse, he would order the therapist to testify or face jail for contempt of court. Abuser did not wish Dr. Silent to discuss any material from their sessions before the grand jury.

Silent felt caught in a particularly difficult situation. In addition, if the Abusers had given Dr. Silent reason to suspect abuse, and he did not report it, he could face prosecution. This situation is a prime example of a point at which ethical behavior may at times seem at variance with legal requirements. Silent believes he should not testify, the best advice would involve resisting disclosure of confidential material using all legitimate legal avenues. If such avenues become exhausted or fail, Dr. If Silent knew of abuse and chose to disclose details from the outset under mandated reporting laws, he would also have behaved ethically.

If Silent had known of abuse and had failed to report it, he could possibly decline to testify, citing his Fifth Amendment right under the U. Constitution against self-incrimination, although such a claim affords no protection from the ethical impropriety of not reporting the abuse. John practices privately as a licensed marriage and family therapist, and Sandra believes that he lied about his income in the process of reaching a negotiated financial settlement. She seeks a court order for her spouse to disclose the names, addresses, and billing records of his clients so that she and her attorney can verify the actual annual income from his practice.

Spleen stands in a difficult position, even assuming that he has nothing to hide in his personal financial affairs. Disclosing the names and addresses of his clients could certainly prove embarrassing and stressful to the clients. Perhaps he could arrange for an independent audit of his records in confidence by a bonded professional, without the need to contact clients individually or otherwise disclose their names. These require a signed authorization by a person with the power to give consent for themselves or permission on behalf for a child or person over whom they have legal guardianship.

Billing for couples and families can become complicated when financial expectations have not been clarified and when third parties become involved. In the newest version, DSM-5, these codes appear in a chapter titled: Whenever some company, agency, or organization other than the therapist and client becomes involved in payment, we have a fiscal third-party relationship. There is no doubt that these third parties, their reimbursement policies, and the regulations that govern these policies have historically had a direct and powerful influence on practice and client care.

Although some well-established therapists have refused to accept third-party payments Barnett et al. Although many therapists will have no difficulties in their relationships with these entities, very few will consider them an unmitigated blessing. This is especially true when attempting to serve couples and families for the reasons summarized at the start of this section.

Attempts to conceal the actual nature of the service rendered, or otherwise attempt to obtain compensation in the face of such restrictions, may constitute fraud. Exactly what services are covered under any given insurance policy is a matter of the specific contract language. Becky and Barney Bicker have been separated for three months and have filed for divorce.

They are contesting the custody of their two children. Their respective attorneys suggest a psychological consultation to prepare a forensic report for the courts on the best interests of the children. They are referred to Bill Lesser, Ph. Lesser assures the Bickers that their health insurance policy will cover his fee and proceeds with the evaluation. He subsequently files an insurance claim for his services without noting that it was conducted primarily for resolution of a custody dispute.

Rotator must identify a single client as the focus on treatment. His first thought is to designate Cleo, but Mr. Chaos expresses a preference for designating his wife because she has already met her deductible payment for the year on other medical services. Designating her would mean that no further deductible would be owed, saving the family out-of-pocket cash. Both of the clinicians described above may be competent and caring professionals, but their business practices may put them at odds with ethics committees or licensing boards. Lesser has engaged in unethical conduct and flirted with fraud charges.

Perhaps he has not carefully inquired of the third parties in question regarding whether the services are indeed covered and is simply trying to expedite claim processing.

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On the other hand, Lesser and Rotator should recognize that the specific services rendered in both cases may not qualify as being mental health related or as treatment of an illness. What appears expedient and helpful to the client i. The most appropriate behavior would be, when in doubt, to check with the third party for explicit advice and to inform clients accurately early in the relationship about whether their coverage applies. Lesser may not understand that services rendered for forensic purposes may not qualify as medically necessary health care under insurance rubrics.

He also may fail to grasp the hazards of confusing treatment with a custody evaluation, creating significant role complications. Lesser has concerns that health insurance will not cover his services and worries that the Bickers might squabble over paying for his time, he may reasonably consider requesting a retainer before initiating services.

Rotator may believe that all four members of the family have emotional problems. He may see no harm in accommodating Mr. If the case were reviewed and Mr. Polly Substance, age 13, was brought to the office of Over Thinkin, M. Her mother was concerned that Polly had been caught smoking pot at school.

Her father has a history of problems with alcohol and has allegedly been physically threatening to his wife. Polly also has a history of learning disabilities and depression. Thinkin recommended family therapy at least once per week to begin addressing the multiple problems in the family. The preference of some managed care companies to prescribe medication instead of therapy is well documented Protos, , and most often these medications will be prescribed by an internist, pediatrician, or nurse practitioner rather than by a psychiatrist Koocher, The ideal ethical conduct of the therapist would first involve firmly but respectfully explaining the reasons for the recommended treatment plan.

Cite supportive research and other factual data whenever possible. If the case manager does not agree, respectfully ask about the appeals process or ask to speak with a supervisor. Again, make the case in a thoughtful, rational manner, stressing the potential adverse consequences of not following it e. If there is still no favorable resolution, therapists should meet with their clients and present both their recommendations and the response of the benefits management company.

Clients should also be told of their own possible recourses e. The three ethical principles involved here are holding the best interests of the client paramount, advocating for the client in a professional manner, and involving the client in the decision-making process. As a legal concept, fraud refers to an act of intentional deception that results in harm or injury to another. There are four basic elements to a fraudulent act:. The resulting injury may include financial, physical, or emotional harm.

A variety of unethical acts might be considered fraudulent. We know of one rather unusual case in which a member of the clergy who was also licensed to practice psychology billed for performing a wedding by creating bogus therapy records for a couple. The insurance company turned his case over to the authorities for criminal prosecution as well as to the licensing board that held jurisdiction. That fact may tempt some clinicians to overlook the hazard. However, because fraudulent billing invariably involves mailed paper transactions or electronic transmission, some violators my find themselves charged with mail or wire fraud if the value of the offense seems to warrant it.

One need look no further than the passionate debate over gay marriage in the United States to see the intensity of social, religious, family, and individual feelings on a single issue. Access to abortion, responses to domestic violence, racial profiling, mandatory drug sentences, and many other such issues raise powerful feelings about risk, discrimination, and personal values. Mental health professionals will have strong views on these issues, as will our clients.

One key ethical issue involves the need to rely on sound evidence as opposed to personal opinion when addressing a clinical case on such topics. This will include assessing whether we can competently work with the clients or should consider a referral. When dealing with clients who are immigrants, refugees, or whose strongest cultural roots lie outside North America, our laws may seem strange.

Western legal culture relies on ideas such as corporations, contracts, estates, and individual rights. These concepts do not exist in some cultures and are treated quite differently in others. Often such differences relate to personal decision making, family life, religion, sexuality, and even the definition or meaning of what mental health practitioners in North America might deem psychopathology. Traditional African law focuses on social considerations and resolving disputes via restitution of social relationships rather than a definition of right or wrong.

As another example, traditional Islamic law engages the larger culture where knowledge, rights , and human nature play central roles. This might include attention to social origins, connections, and identity. The key values of traditional law in Islamic society focuses on restoring relationships and easing the resolution of disputes with considerable negotiation and judicial discretion Post, Consider how some cases with legal ramifications might play out in the context of individual differences.

Rivka Cohen has been in an unhappy marriage with her husband, Shlomo, for five years. Rivka has sought treatment for depression and anxiety in the context of documented physical and emotional abuse with Dee Lemma, L. Lemma that she has asked Shlomo for a divorce, but he has refused. A civil divorce in the absence of the religious document would put her at odds with her community. He was asked to consult on the case of Mrs. Sato, an year-old woman who lives with her daughter and son-in-law in the United States.

Sato speaks only Japanese, although her daughter and son-in-law are fluent in both Japanese and English. Sato has been admitted to the hospital with abdominal pain and is quite anxious. The diagnosis is gall bladder cancer, but the only people at the Hospital capable of communicating the diagnosis to Mrs.

Watanabe and members of her family. The gastroenterologist has asked Dr. Watanabe to help explain the diagnosis and treatment options, but the family members express a wish to do it themselves. Watanabe in Japanese that they do not believe Mrs. Sato can handle the news, and plan to tell her that it is a simple gall stone. She understands how emotionally distressed Rivka feels, but is stunned by the kidnapping plan.

Rivka will not be talked out of the plan, and Ms. Lemma now wonders whether she has a duty to breach confidentiality to warn Shlomo or to report a planned criminal act kidnapping to the authorities. After investigating the situation via online searching, Ms. Lemma learned of an FBI sting operation to stop such practices Bever, and wonders whether her client may become the victim of further violence from Shlomo if she warns him or perhaps face prosecution as a co-conspirator if she contacts the police.

This might be an opportune time for Ms. Lemma to discuss potential repercussions with Rivka, including Ms. While attending medical school in Japan, Dr. Concepts of informed consent in Japan and the United States have many significant differences and it is not unusual for physicians there to deal chiefly with family members rather than involving the patient directly in medical decision-making. Watanabe wonders about his obligations under U. Perhaps, instead of allowing himself to be used as a linguistic interpreter, Dr. Watanabe can try to educate his American colleagues by interpreting the cultural issues involved and engaging a more interactive approach between the family and medical staff.

Daleela Abbas, age 16 years, emigrated with her family from Iraq a decade ago. She comes from a devout Sunni Muslim family, and has come to a community clinic on her own, complaining of depression. During an initial intake visit, she begins to sob and discloses that she had sex with a year-old boy who graduated from her high school last year. Because of the age differential, or other factors, this might trigger a mandated report to child protective services.

However, the girl fears that if her parents are told or learn of it from seeing clinic records , she will not be alive for more than a week. This case presents many layers of complexity and to some extent may depend on state law, insofar as whether or not a mandate exists to notify authorities about the self-reported intimacies with the year-old. The critical issue involves protection of the most vulnerable party, Daleela.

Taking protective steps seems urgent, and those could involve the necessity of seeking protective orders and alternative, well-protected living arrangements. Expert assistance from culturally knowledgeable individuals will be needed to plan the best course of action. Any protective actions will doubtless trigger intense social pressures on Daleela to cease discussions of personal issues with those outside her family and to return home, while also putting her at great risk.

Creating incomplete records by not documenting the facts may result in failure of authorities to act effectively. At the same time, access to such records by family members could also create a significant hazard. These cases will require sophisticated cultural knowledge in order to craft interventions that adequately protect the children. The mental health clinician must stand ready to work for a suitably protective solution. In all such cases culture, tradition, or religion cannot become an explanation or excuse for not taking protective actions.

We may not have the ability to protect vulnerable parties from harm beyond our sphere of professional control, but we cannot ethically neglect our obligations to our clients. We readily acknowledge that some societies, particularly in Africa and Asia, do not place the same value on individual rights, as opposed to community rights, as do most Western societies. Therapists must remain sensitive to and respectful of cultural differences in this regard. At the same time, we must also obey the laws of the jurisdictions in which we practice. At times, this may create tensions that require helping people from other cultures to understand applicable laws and regulations that apply in the immediate circumstances at hand.

Shalom later complained to the state licensing board that Ms. Talmud had discussed matters she disclosed in therapy to the family rabbi without her knowledge or consent. The rabbi in turn communicated some of the content to Ms. The licensing board censured Ms. Talmud, reminding her that she treated Ms. Shalom in her capacity as a licensed marriage and family therapist in the United States, not Israel.

In addition, basic ethical principles of autonomy and human dignity entitled Ms. Shalom to have a voice in any decision about disclosing material she had offered in confidence. Child custody disputes are among the most common triggers of licensing board and ethics complaints. Clinicians should not venture into this forensic arena without specialized training and expertise.

That said, sometimes family therapists do find themselves entangled. Ben and Bettina Bombast felt so angry toward each other about their impending divorce that they could not seem to agree about anything. They certainly could not imagine agreeing on custody plans for their children, Barney and Bella. When Hugh Kidder, Psy. The Bombasts were amazed by Dr. Kidder issued a report to the court in support of their joint decision. A few weeks after the divorce became final, the Bombasts both contacted Dr.

Kidder at his private office. Barney was having some school adjustment problems, and both parents agreed that they would like Dr. Kidder to evaluate and counsel him. They expressed considerable mutual confidence in Dr. Kidder because of their previous experience with him. Kidder would first have to carefully consider and discuss with the Bombasts the nature of this role transition.

Once he agrees to become the therapist for one member of the divorced family, he could not reasonably resume a mediator or evaluator role should the Bombasts again begin to bicker. His primary obligation would have become refocused on the best interests of their child. Assuming that all agree and that no other roadblocks exist, Dr. Kidder could ethically proceed in his new role. Bob and Harriet Splinter have decided to divorce and want to do what is best for their three young children. They seek therapeutic consultation with Connie Sensus, L.

During their sessions together, Bob acknowledges that Harriet would be better as the custodial parent because he has a drinking problem and was involved in some unsavory delinquent conduct as a youth. They agree that the children will live with Harriet, and that Bob will have frequent visitation.

Just before finalizing the full divorce agreement, Bob and Harriet have a falling out over financial issues, and Bob states his intent to seek sole custody of the children. Harriet wants to call Ms. Bob demands that Sensus keep confidential all that he told her. In some jurisdictions, any rights of confidentiality that Bob or Harriet might assert with respect to their own mental health records could potentially be set aside if deemed in the interests of the children by a judge.

Sensus had raised this issue at the outset and had obtained consensual waivers i. She conducted nearly 20 hours of interviews with the parties, the children, and collateral sources. Much of the information she gathered was relevant to the matters before the court, but some was extraneous e. Fragmento wore a poor-quality hairpiece; Mrs. Fragmento is at least 30 pounds overweight; and the maternal grandmother recently underwent a facelift.

The extraneous data made their way into Dr. She will now complete her report, citing all relevant factors, and either will not cite or will discard all extraneous material. The procedures employed by Dr. Meticulous are entirely appropriate. If material she gathers proves relevant, it should become a part of the case file and her report.

If any of the data collected prove to be irrelevant, they should not become a part of the permanent file. American Psychologist, 30 , American Association for Marriage and Family Therapy Marriage and Family Therapy Core Competencies. The principles of medical ethics with annotations especially applicable to psychiatry. Let therapists be therapists, not police. The American Journal of Bioethics, 13 , Boundary issues and multiple relationships:

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