ETH1101 - SECTION 6: DEFINING THE CLINICIAN/CLIENT RELATIONSHIP
Defining the Clinician/Client Relationship
The decision tree and the stages form the core of the decision making process. These two tools, however, are only successfully applied when there is a defined clinician/client relationship.
As mentioned previously, there are two other questions to be simultaneously answered about the nature and boundaries of the clinician/client relationship.
Defining the Clinician/Client Relationship
Who is or who are the client(s)?
When does the clinical work take place, and when is the client considered a client?
We'll begin by looking at questions concerning who the client is. When there is a single, adult client, who has contracted with the clinician for counseling services, ethical decisions are at their easiest in this regard.
But who is the client if the clinician is seeing a family for family therapy? Or a couple for couples counseling? Who is the client if an employee is referred by a company for a counseling session with the Employee Assistance Program: is the employee the client, or the company that pays for the services, or is it both?
These issues are important because in looking to establish a method of determining the most ethical course of action, you need to see whose best interests are at stake, whose autonomy must be promoted, who must be protected from harm.
When there are multiple parties involved in the counseling process, there exists the possibility of a conflict of interests between two or more of the parties involved in the ethical situation. It might transpire that in choosing a course of action, you promote the welfare and interests of one party, but harm the interests and welfare of another.
What are the guidelines for determining who is or who are the client(s), and whose needs, rights and protection from harm are more important? Some of the information for these guidelines comes from our decision tree, although in an inferred way, rather than in a straightforward way. Some of the information is also related to the other question to be raised in this section - when is the counseling taking place?
To begin with, a client is someone whom the clinician has agreed to see, and who has agreed to see the clinician. In the case of a minor child (or an adult who lacks the capacity to make his/her own informed decisions, and for whom a guardian has been assigned) the agreement to see the client is usually reached with the parent or guardian.
Promotion of the autonomy of the client and/or his/her guardian moves to center stage in this instance. If the client (or his/her guardian) does not autonomously agree to the therapeutic relationship, with both its rights and its responsibilities, then the person does not become a client.
Ideally, the exact nature of what this agreement for counseling means should be spelled out for the potential client prior to entering into a therapeutic relationship. A formal statement of understanding is a good tool for fulfilling this aspect of the therapeutic relationship.
At the initial point of contact, the clinician may also elect not to enter into the therapeutic relationship. And the clinician may specify aspects of the counseling arrangement - like how high fees are set - that result in the client electing not to enter into the therapeutic relationship.
This is one of the instances in which the clinician's rights to autonomy may be legitimately asserted, since the therapeutic relationship has not been formally entered into, and the clinician does not yet have obligations to the client's well being that supersede the autonomy of the clinician.
Even here, however, the clinician's right to autonomy may not be asserted if in so doing it brings avoidable and significant harm to the person who has come seeking services.
For instance, when a prospective client calls a clinician to seek services, obligations exist towards the safety of the client even in the course of the first phone call. The clinician may not ethically decline to help the client find appropriate help - if the prospective client is suicidal or otherwise at risk for safety related concerns - simply because the prospective client has not agreed to the therapeutic relationship. The duty to do no harm supersedes any other considerations on the decision tree, even before the therapeutic relationship has been formally agreed to and fully defined.
This responsibility is one of the obligations that is demanded of the clinician in accordance with the right to practice the profession. When more than one person is involved in the therapeutic relationship, each person receiving counseling services can be considered a client. This means that the nature of the therapeutic relationship should ideally be negotiated and defined with each and every person who receives the clinical services.
When two or more clients are equal co-clients, as in couples counseling, family therapy, or group therapy, then the responsibilities and rights for each must be equally clarified.
When persons attend counseling sessions as an adjunct to the client's counseling, as when family members attend a session to give background information or perform some other function in support of the client's counseling, there is still an ethical responsibility for the clinician to define the nature of the relationship for all the parties involved in the session.
Within the legal dimension of practice, there are state laws that must be known with regard to the rights of each party in the therapeutic situation. From an ethical stance, however, there are also certain obligations to do no harm to adjunct parties to clinical services, as well as obligations to promote the well being and autonomy of the adjunct parties.
In practical terms, this means that a clinician must consider the harm that can be done to co-clients or participant parties adjunct to the clinical services when utilizing strategies designed to promote the well-being of other clients.
Interventions that involve the confrontation of family members by the primary client in a counseling session, for instance, present serious ethical problems if the rights and autonomy of the parties being confronted are not considered.
This is because whether a participant in a counseling process is an identified, primary client, a secondary client, or an adjunct participant in the counseling process of another person, he or she can be considered a client of the specific counseling process in which the clinician has engaged him or her.
This means that the fundamentals of the ethical process for each person remain the same: defining the nature of the relationship, evaluating the ethical process via the decision tree, balancing the competing interests, involving the client in the decision process.
This can present particular difficulties when the primary client is a child, or an adult who has been declared incompetent. In such cases, the parent or guardian has a right to autonomy in making treatment decision on behalf of and for the benefit of the client. In such cases, the parent or guardian is the client when it comes to the autonomy aspects of the decision tree.
This is because the primary client under such circumstances is not viewed as being capable of handling the responsibilities of autonomy, so is therefore not completely accorded the rights of autonomous decision making.
But the rights of the minor child or incompetent adult to autonomy are not completely denied, nor the rights of the parent or guardian to autonomy completely protected. Again, there are variations from state to state in terms of how absolute are the parental rights to treatment decisions versus according some rights to a minor child.
Moreover, the child or incompetent adult's rights to be protected from harm supersedes the guardian's right to autonomy - hence the existence of protective services in the states - and the child or incompetent adult's rights to have his or her welfare and autonomy promoted operates, in many instances, at least on an equal footing with the guardian's right to autonomy.
The presence of multiple clients, or even multiple participants, in the therapeutic process obviously requires that the clinician engage in a process of evaluating numerous competing interests in coming to a decision about ethical choices.
In many states, whenever a client enters into, or contacts the clinician for the purpose of entering into, a treatment relationship, then certain rights are created on behalf of the client. One of the most important of these rights is the right to privileged communication, whereby any communication between the client and the clinician is considered private and protected by state and federal statutes from obligations to be released by the clinicians without either permission of the client or some law or statute that supersedes the right to privilege.
If additional clients enter into treatment as part of the process of treating a couple, a family or a group, then the same right to privilege is likely to be accorded to that party. However, this same principle may not apply if an individual does not create a treatment relationship with the clinician, but has a peripheral role as an adjunct party for the purposes of providing background information, or transporting the client, or some other purpose that does not involve active participation in the treatment process. Because there may be some variation from state to state in terms of how matters of client privilege are handled, clinicians must remain up to date on the laws and statutes that apply within their state.
In the analysis of the scenarios, there will be a good deal of focus on the subtleties of this difficult balancing process. More in-depth study of this issue will therefore be held for that time.
The next question has to do with when a client is a client. This question has, to some degree, been defined with regard to the beginning of the therapeutic relationship. There are, however, two other points at time for which some definition is required.
The first of these other points in time is while the therapeutic relationship is occurring - but outside the defined counseling hours during which the counseling is being performed by the clinician.
This is to ask if the client is still a client if the clinician meets him or her in public or in other personal settings? To what extent does the clinician have obligations to the client that supersede the clinical professional's right to privacy or autonomy outside the counseling office?
The answer to these questions is found to a great extent in the decision tree. Prior to being able to exercise his or her autonomy, the clinician must take into consideration whether his or her actions will have an impact on the client that is in any way harmful, will harm the autonomy of the client, or will be detrimental to the mental health profession as a whole.
Most clinicians are aware that this means protecting the confidentiality of the client when meeting him or her in public. However, it also means looking to protect the well being, including the emotional well being, of the client during chance encounters outside of the office.
While this is an imposition upon the free time and autonomy of the clinician, the client's rights to protection from harm, and promotion of well being and autonomy, outweigh the clinician's right to autonomy.
This does not mean that the clinician must stand in public and engage in an impromptu counseling session. The client's autonomy includes responsibilities to work within the confines of the defined therapeutic relationship. This means according to the hours in which the counseling sessions are scheduled.
The responsibilities of autonomy for the client support the rights of the clinician to take care of his or her personal life in a satisfactory manner - if the clinician has done a good job of clarifying these matters with the client.
The other time that is concerned with this issue is after the counseling sessions have been completed. At what point in time does a client stop being a client?
Some of the mental health professions clearly define time limits past which time the clinician is exempt from responsibility towards the client. Other mental health professions state that there is no time limit to the clinician/client relationship, and that responsibilities and obligations to the client exist towards infinity. Which is right?
It is important for the clinician to be aware of the code or codes of ethics that are applicable to him or her in this regard. The various codes of ethics represent the most up to date consensus that has been reached by the bodies involved in studying and evaluating ethical decisions for the specific groups of clinical professionals covered under the code of ethics. The fact that different groups can come to different conclusions is understandable, given the complexity and difficulty of the issues involved in resolving this question.
Following the code of ethics for your group keeps you compliant with accepted practice principles, and protects you from liabilities. While following the code of ethics defined by one's peer group, however, it is also important to understand the principles involved in making these decisions.
The decisions in this regard bring us back to the decision tree. Will disrupting the clinician/client relationship cause undue harm to the client? Will it unduly prevent the welfare and interests of the client from being promoted if all the protections of the clinician/client relationship are withdrawn?
These considerations are counterbalanced by issues related to the autonomy of the client. Does it hinder the autonomy of the client to assume that he or she can never be considered to be on equal footing with the clinician, capable of making autonomous decisions about being the clinical professional's friend, or even romantic partner?
What if the former client becomes so healthy that he or she might make a good mentor, or even a good clinician, for his or her former therapist? Is not the purpose of counseling to aim for such results? These are questions for which there is yet no uniform answer to cover all clinicians in all situations. It raises the issue of different approaches to making ethical decisions.
The first approach, at one end of the spectrum, is to take the most defensible position in any ethical dilemma. This involves knowing, and following one's codes of ethics as closely and carefully as possible.
At the other end of the spectrum, one could attempt to follow the principles of ethical decision making, and the decision tree, as closely as possibly, looking to follow the ideal spirit of the ethical decision making process, even when the decisions that arise from this process conflict with the codes of ethics. In reality, some real life ethical decisions may require that a clinician do a little of both. For this reason, it is important that each clinician both know and understand the codes of ethics relevant to his or her profession, and understand the ethical decision making process.
In the analysis of the scenarios, to which we will now turn, we will see examples of all of these following concepts in action. In the process, it is hoped that a deeper understanding will be reached that will inform good ethical decision making on the part of the clinician.
It also hoped that it will engage each clinician in the process of helping to continue to refine the shared understandings about what is involved in making ethical decisions.
Important Code Updates: Technology, Social Media, Telemental Health
It is important to note that the most recent updates to the Codes of Ethics have addressed a new and disruptive area of social change that has far reaching implications for practice in the field of mental health. This set of changes also has implications for ideas of when the client is a client and when treatment is occurring.
Over the past couple of decades, the emergence of new technologies - the internet, social media, new technological devices - has offered both new opportunities and new challenges for people who engage in mental health practice. The ease of communication with these new technologies means that interactions between clients and clinicians can be more easily achieved, which can enhance the capacity of clinicians to remain in closer contact with clients, refer them to useful resources, and even provide counseling without the necessity of being in the same place at the same time.
However, it also means that clients can do an internet search on the people providing mental health services to them, can easily remain in touch long after the treatment goals have been reached and the treatment has been concluded, and have higher expectations for their clinicians to be available to them day and night.
These changes - and the ethical considerations related to them - have been addressed in yourceus.com's course, Ethical Considerations of Practice in the Age of Social Media and Electronic Communications. The changes include legal considerations of technology, including two updates to the Health Insurance Portability and Accountability Act (HIPAA) in 2010 and 2013 that redefine guidelines for protecting the privacy of Protected Health Information (PHI) in the era of electronic modes of storing, sending and receiving health information.
However, the changes also include ethical considerations of privacy, safety, and the maintenance of professional authority and the professional relationship when personal information about clients and clinicians is so much more easily available on online search engines and social media, and when counseling can be performed over distant modes of communication: Telemental Health.
There can be separate sets of challenges for mental health clinicians in addressing some of these changes from the technology revolution. Clinicians who came of age prior to the emergence of these technologies may not fully understand how to maximize the opportunities presented by increased communication connection.
Younger clinicians, whose formative experiences were in a more technologically connected world - with an enhanced degree of self-disclosure - may have internalized a different sense of what represents an appropriate level of privacy. This may affect their sense of where to draw boundaries for themselves and their clients in ways that clash with values in the Code of Ethics for their profession. They may underestimate the risks of operating in a technologically robust environment while working as a professional in this field.
For this reason, it is important for each professional to keep their ethical knowledge base up to date, and spend some time exploring the implications of these changes for the work that they do.
Post-test Preparation: Review questions
At this point in the training, the trainee should be able to answer the following questions:
When do obligations begin that require the clinician to protect the safety of the client?
Who should be accorded informed consent when meeting with multiple clients and/or adjunct parties to a therapy session?
What general responsibilities for maintaining the integrity of the profession exist when clients are encountered outside of therapy sessions?