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Therapy – Ethical Standard 10

Ethics

Read the APA Ethics Code – Standard 10

Suggested Readings

Services by Telephone, Teleconferencing, and Internet
Your Rights as a Psychotherapy Client
What I tell people about therapy

Useful Notes

Illinois Law on therapy
15/3 (f) Duly recognized members of any bona fide religious denomination shall not be restricted from functioning in their ministerial capacity provided they do not represent themselves as being clinical psychologists or providing clinical psychological services.

15/3 (g) Nothing in this Act shall prohibit individuals not licensed under the provisions of this Act who work in self-help groups or programs or not-for-profit organizations from providing services in those groups, programs, or organizations, provided that such persons are not in any manner held out to the public as rendering clinical psychological services as defined in paragraph 7 of Section 2 of this Act.

15/3 (h) Nothing in this Act shall be construed to prevent a person from practicing hypnosis without a license issued under this Act provided that the person:
(1) does not otherwise engage in the practice of clinical psychology including, but not limited to, the independent evaluation, classification, and treatment of mental, emotional, behavioral, or nervous disorders or conditions, developmental disabilities, alcoholism and substance abuse, disorders of habit or conduct, the psychological aspects of physical illness,
(2) does not otherwise engage in the practice of medicine…
(3) does not hold himself or herself out to the public by a title or description stating or implying that the individual is a clinical psychologist or is licensed to practice clinical psychology.

Illinois Law on Sex with Clients
Section 1400.80 Unethical, Unauthorized, or Unprofessional Conduct
The Department may suspend or revoke a license… based upon its finding of “unethical, unauthorized, or unprofessional conduct”… which is interpreted to include…
i) the commission of any act of sexual misconduct, sexual abuse or sexual relations with one’s client, patient, student supervisee or with an ex-client within 24 months after termination of treatment;


Other Issues Related to Therapy

Consent to therapy
Illinois is a little confusing on this. However, the basic points are:

  • If the client is under 12, therapy requires consent of the legal guardian, usually the parent. If, however, a family divorces and one parent is given sole legal custody, the noncustodial parent loses the ability to give legal consent.
  • If the client is over 18, this requires consent of the adult patient, or if they are incapacitated, the consent of their legal guardian.
  • If the client is 12 to 17, this requires consent of both the parent/legal guardian and the client.

Clients, Therapists, and Harm Sex with Clients
The Hippocratic Oath for medical doctors precludes sexual relationships with patients. This is to remove the focus on personal gratification in professional relationships; however, this is impossible to some extent, since you are going into this field because you want to. You will obtain rewards from your work, just like other psychologists. There is nothing inherently wrong in this, and admiration and respect, learning, and finding out about others’ lives in a way that is close to walking in their shoes can be very powerful reinforcers. However, we have to make sure our clients are harmed by this.

Sexual interactions with clients appear to many as basically a form of sexual abuse due to the “one up” position of the therapist, and the vulnerability of the child. While perhaps not as emotionally powerful, the supervisor/faculty and student relationship is similar. The power difference there may simply be more brute and frightening than therapy. They note that it starts with small “slippings” of the boundaries, from sharing your life, to obvious attraction, to flirting, to touch, to contact outside the office, and finally to sex.

Koocher and Kieth-Spiegel note that sexual attraction is normal, and 95% of male and 76% of female therapists have felt attraction to a client; however, the 1986 study indicated that about 10% of male therapists and 2.5% of female therapists had acted on it. The 1994 study by Rodolpha indicated that only 4% of all therapists acted on it. About one third in a study by Pope study said they thought clients had been attracted to them.

They offer 10 warning signs that normal attraction is a becoming a problem:

  • thinking about the client outside of sessions
  • having sexual thoughts or fantasies about a client
  • unusual attention to your appearance in sessions with the client
  • asking questions of the client to satisfy your personal curiosity, especially sexual ones
  • daydreams about contact outside the session
  • being mildly flirtatious
  • having rescue or savior fantasies about a client
  • being sexually aroused in sessions
  • thinking of yourself as being able to make up for past hurts
  • wanting to touch the client

They discuss touch with clients as well. While half the therapists in a study thought touch could be helpful, only about a quarter did touch their clients. Freud in his writings responded to questions about touch by indicating that it could be helpful, but the issues of regression, erotic transference, and the therapist’s own needs could make it a slippery slope of sorts, and recommended drawing the line at any touch. There are often sexual feelings of some sort between the client and therapist (often one way) that come into this, but feelings of parental protection and desires to regress can often come into it.

While some schools do support client touch, it can be an intervention that is mistimed and poorly offered, just like an improperly offered interpretation or offhanded comment. If you touch one sex more than the other, be willing to look at this as a sign of boundary slipping.

They also touch on the “As If” quality of therapeutic intimacy. You know your clients very well, but they do not know you. Thus, it is “as if” you are close but you aren’t. Most therapists that start sexual or other avoidable dual role relationships fall into the trap of seeing that as real and crossing the lines to get their own emotional needs met. They talk of manipulative therapists, sex therapy, and drugging or raping therapists.

They discuss post-therapy sex with ex-clients, pointing out how therapy is often terminated badly, more to meet the needs of the therapist than anything else. Further, the way people view the trust they put in the therapist might change if sex were accepted between therapists and former clients.

They also discuss sex with relatives or friends of clients. Another verboten activity, since the dual role is likely to result in harm to the client.


The Management of Sexual Feelings in Therapy

Rodolfa et. al. PPRP 25(2) 168-172

88% of respondent therapists admitted to sexual attraction to clients, sometimes to clients of the same sex. Younger and male therapists were more likely to be attracted to clients. Physical attractiveness, cognitive traits, character, sexual presentation of the client, kindness and vulnerability were listed as reasons for client’s attractiveness. However, 79% denied sexual fantasies based on their feelings. 55% felt anxious or guilty about their feelings, 92% reported never considering action upon the attraction, 4% considered but didn’t act on it, 4% acted.

The 4% who acted listed divorce, being single, job loss, low self-esteem, and naivety as reasons for acting. 48% said awareness of these feelings helped the way they conducted therapy, 43% said they hurt therapy. 64% thought attraction was mutual. 60% sought supervision or consultation. 40% got no graduate school training on this, and 51% got no internship training on this.

Other studies have shown that psychologists who did have sex with clients were more likely to have had sex with faculty, and come from a program where faculty showed similar poor boundaries.

Older studies indicate more male acting out, and more rationalization of it. The numbers for sexual intimacies with clients continue to go down though.


Some Ideas About Ethics

First, at one level, “right and wrong” should have nothing to do with ethics; rather, ethics have to do with ethics. When people start with what is “right” and what is “wrong” they too often start from their own standpoint and make the bigger picture “bend” to fit their best interests. When a conflict occurs, you start with the Ethical Standards which are like minimum standards for expected behavior from a psychologist, given the bigger picture that our field has taken the time to consider. If the Standards don’t provide sufficient guidance, move on to the Ethical Principles which provide aspirational goals for your decisions. If they don’t guide you, move on to your personal values. However, I tend to doubt that most people have values that aren’t covered at least in some general way in the Preamble and Principles. Of course this is not to say that we make ethical principles without regard for “right and wrong,” but rather that we start ethical decision making with the minimum expectations for our field, an eye to the “big picture” beyond our own personal concerns, and then turn to personal values about right and wrong.

Thus, I tell students two things about ethics:

  • the answer to “Is it unethical to…” is “What does the ethical code say about…” Look for specific ethical guidelines, then go from there
  • any ethical answer that starts with “Well, technically…” is a bad ethical answer. The aspirations of the code do not hinge on technicalities, but the best interests of our client

Second, ethical codes can not “tell you what to do” in black-and-white terms because a) they can not cover every situation and b) rules do not replace good judgment. Unforseen issues, twists that make two apparently similar issues different, and ethical “lose-lose” situations come up.

Consider how giving an insurance company a client diagnosis (that does accurately describe them) and sensitive information about their problems could get them coverage now, which is helpful, but could cause problems for them later in the form of information that the company does not handle with appropriate confidentiality, which are harmful. Not giving the serious diagnosis they deserve would result in no coverage, harming them now, but prevent mishandling of that information, helping them now.

Does this mean at the first session that you present a consent for treatment, a page explaining that not everyone gets better in therapy and some people get worse, a notice that you may send them to collections for failing to pay their bill, and statements about the limits of confidentiality, and then ask them to sign and date all this? It would be ethical and well-documented, but would scare them off from therapy for sure.

In these cases, you have to choose what to do based upon the particulars of the situation, following the Standards and then following the Principles in the ways you can, and then exercise good judgment. In short, the ethics codes mandate only that you are up-front and honest with those you work with, and keep the client’s best interests as paramount.

Termination of therapy
When termination occurs and you and the client are not in agreement, it can signal problems. You can’t “scare them” into staying in therapy, but you have to tell them what you expect will happen, if anything. You also must be ready to assume some professional role later when a crises occurs, regardless of any fees that may be remaining from their therapy. To do otherwise would likely constitute some form of abandonment.

If at all possible, have a pre-termination session. Possible topics include for discussion would include

  • what have they learned or what has changed for them
  • what did therapy do well? not so well?
  • future problems they foresee or issues they will one day address
  • what if they needed to come back
  • any confidentiality issues left

Ending Practice
Agreements about leaving a practice at some point should be clear at the outset, as should any non-competition clauses. Client welfare must be considered; you likely should not mandate a therapist must abandon clients, giving clients no choice about whom they see. Or, if this is mandated, this should be explained to the clients at the outset (e.g., your insurance company would not transfer coverage to a new practice). Likewise, a flat fee to take clients might be ok, but it can’t be passed on to the client.

At our own practice, we have a clear policy in our agreement that conviction for ethical violations constitutes grounds to expel you from the practice. This is an effort to insure ethical behavior, as well as to protect the rest of the group in some way from unethical behavior.


HMOs and MCOs

You’ll be able to tell fairly clearly here that I don’t like insurance companies. Let me be clear on that. Some, more likely PPO’s and the like, are pretty good about respecting the clients rights and best interests. Others, more likely MCOs and HMOs, are more concerned with profit. That doesn’t mean everyone working for them is concerned only with profit, but it does mean that profit figures into the organizational policies that effect their decisions.

Koocher and Kieth-Spiegel correctly note you are unlikely to be able to avoid them in practice. However, the reason they exist is partially our own fault. Our services are not free and so someone had to come up with a way to pay for them, and there has been a lot of billing fraud in the health care field and so someone had to come up with a way to control the costs. We have fought with them over FOC legislation, as well as with “the smaller fish” that are trying to eat into our field and doing it with the insurance companies’ help because they are cheaper. They have fought with us over best care and use of insurance coverage, what is a “right,” and what is not.

Health insurance is not (health insurance). It’s actually, in their minds, “sickness insurance.” Unless the “problem” is sickness, many insurance companies don’t think they should have to cover it. Question: Do you have a right to Viagra and does the insurance company have an obligation to pay for it? It depends on whether you think erectile difficulties are a “problem” like a failing kidney, or just something “nice” to change, like a nose job.

Ultimately, you can not turn billing responsibility over to anyone else when you become a professional unless you are very sure it is all above board. You don’t sign blank billing forms, “pad the bill,” alter your fee, or otherwise act in any “sneaky” way. If you can’t do it above board, it is likely illegal or unethical. If you aren’t sure that the people working for your on billing tasks are above board, you likely will get into trouble. Take something like agreeing to lower fees to get the contract, then raising them to compensate when client coverage expires; this is unethical and illegal.

Say you normally charge $100 an hour, but agree to $80 an hour for the six sessions you provide for them. You have lost $20 times 6 hours = $120. A client wants to continue, but the insurance company doesn’t pay for more sessions. So, you charge the client $120 an hour, figuring 6 sessions of an extra $20 per hours makes up for what you lost. This means you have treated the insurance company patients differently from other patients not on the plan, and this violates the contract you have with the insurance company, ultimately exploits and hurts the client, and is unethical for both reasons.

Also remember you are responsible for debt collection actions (so a company that calls them at work and harasses them is acting illegally on your behalf). You should also get consent at the outset of therapy to turn over billing to a company if they fail to pay. At the least, you must inform them before turning them over to a collections company. You also can not manipulate clients to “get what’s owed you.” You can’t make “psycho-terrorist comments” like “You would have lost your job if you hadn’t come to therapy and improved while working with me. Don’t you think you owe it to me to pay your bill?”

When insurance companies cut off payment for treatment, desire ineffective treatment plans, or try to exploit you, you are still responsible for the coverage of the client. When the company refuses to pay for adequate coverage, you are supposed to clearly point out to them that this is inadequate coverage for the client’s needs. Document the name of the person you spoke to, and the time and date of the conversation. Make clear that you will document this and share it with the client. Of course, if you are not speaking with a psychologist, you should speak with one and discuss it with him or her. The authors present a case in which a medical doctor was found guilty too when an insurance company mandated inadequate care and he did not protest.

Complete honesty and openness with the client is your best bet, and remembering that you are the expert on the client, not one of their staff. Present issues regarding limited treatment, continuation with the client coverage of the fee, or referral if you have to.

When they cut coverage, you can not “dump” the client. When they refuse to approve new sessions without a three week waiting period, they will make you wait but will expect you to provide coverage without any guarantee of payment from them or ability to bill the client. For you to do otherwise could be a form of abandoning the client. They may play the “That was an authorization number to offer treatment to our member, not an agreement on our part to pay for treatment” game.

Ultimately, insurance companies are bigger than us and can get away with this. However, in my opinion, this hurts the client. Many “good therapists” often don’t have time to work twice as much (therapy plus filling out forms, talking to untrained case reviewers, and completing and re-completing and filing and re-filing forms…) for half the fees (which the insurance company dictates in the contract) that take longer to collect (my record is six months for an insurance company to pay for services after I filed forms three times and had the billing manager follow up each time). Clients may end up getting mostly the financially desperate clinicians, or may be expected to pay out of pocket which means the client foots the bill for the treatment until and if the insurance company reimburses. This is not the kind of coverage the client expected when they signed up for mental health insurance.

Remember when we asked why we have an ethics code? Another answer might be that we would end up being like some insurance companies if we didn’t have a code of ethics that mandated fairness, integrity, and welfare of the client as paramount.

  1. Lori Holloway says:

    Hormones are drugs. I think we need to seriously take a hard look at the idea that there is such a thing as a “normal” attraction to clients. I don’t pay anyone to be attracted to me, and I don’t expect my clients to, either.

    The fact is that the people making decisions about what’s ethical are the very ones with erections during sessions. Yet I fear testosterone impaired cognition impairing clinical work is rampant. I have heard too many stories about questionable advice and treatment with a sexual dynamic in the office, never acted on and probably judged to be one of those “normal” situations you mention.

    I don’t believe most human male therapists are capable of absolutely disconnecting their blood hormone levels and sexual responses from the clinical process. We need more hard research on this, reviewing treatment processes and arousal rates.

    I fear this is epidemic, honestly. I’m not anti-male at all, just a proponent of research and evidence based work. The clinician’s office is no place for an erection. Ever.

    • I’m not sure how to respond to some of your comments. I think you’re right that humans are built of emotions, chemicals, social pressures, personal biases… and so we can’t disconnect our hearts, hormones, chemicals… from who we are.

      I don’t think the research above asked about erections in session, but rather about attraction. It’s one thing to sexually desire your clients, another to realize they are good people and you feel drawn to them in some way (maybe because they are like you in some way). That’s very different from sexual attraction and arousal.

      It’s a possible starting point to “slip” down the slope, however. Along the way are lower quality care and lost boundaries, and at the bottom is likely abuse of clients, so attraction (before it gets close to arousal) certainly deserves some discussion and monitoring. However, discussion and monitoring isn’t arousal – in fact, it’s designed to prevent arousal and provoke professional thinking, reflection, and establishment of boundaries. What is it about you as a therapist that makes you have these feelings? What does this tell you about your work with your client? Can you control your emotions?

      The ongoing data from researchers and malpractice companies about psychologists is that sexual abuse of clients is a stable 3-5% depending on how you ask about it. I don’t think it is an epidemic… I’m not saying 3-5% is an acceptable ratio, but it is also not an epidemic.

      If you are including other professions in with psychologists, then I have to admit ignorance there. I don’t know any statistics on social workers, counselors, etc…