On first glance, it seems contradictory to conduct a business and observe the ethics of your chosen profession. What do we do when we need to inform a mainstay of our referral base, say for instance a medical practitioner, that the rationale for their referral is invalid? Let’s examine the following scenarios.

Dr. W. Smith has been a steady source of interesting referrals. He sends you a case for the management of his patient’s depression and social anxiety. On further investigation it becomes apparent that the patient has neither symptom, but is requiring sick leave. Essentially, it appears that his doctor wants you to agree with his diagnosis, which he has used to complete his patient’s medical report. He has stipulated that his patient be seen by a Registered Psychologist in addition to following the psychopharmacological plan which he will supervise. Turning to the business of money-making, your fees will be fully covered by the patient’s insurance plan.

Let’s examine yet another scenario. You are board certified to do forensic work. A defense lawyer, who routinely sends you lucrative assessments, asks you to assess his client. He gratuitously also mentions in passing that he has appreciated the quality of your work; which has assisted in the defense of clients. You perform the assessment using appropriate instruments targeted to the client’s normative sample. You interpret your results and realize that given your findings, the lawyer will most likely be unhappy because the findings point to recidivism, among other pathological traits.

Or what do you do when a client you are treating is a famous hockey player who offers you tickets to the next game? In passing, he mentions that his wife is pleased with his progress and would like to attend some sessions of marital counseling with you. His wife calls and makes a similar request after expressing sheer amazement at your ability to facilitate some profound changes in her husband; which no one has been able to do. She is adamant that they need to see you, and no one else.

In the literature, the often encountered and unavoidable dual and multiple roles are discussed. The generally agreed upon stance is to steer clearly away from the “slippery slope” by keeping boundaries intact and not forming social relationships with our clients no matter how subtly these boundaries may appear to evolve. To say that after a period of X years after termination of treatment, we can have a social relationship with our client is difficult to justify: how do we best serve a client if they seek our assistance at a later date? To the client, we seem the obvious choice, given our knowledge of past history. Thus, when clients mention they view me as a friend, I review what the expectations were on intake: as fees, expectations and surrounding vacation and absences, and most relevant here: the therapeutic relationship Turning to the ethics around confidentiality can also illuminate the “slippery slope”, especially when clients ask us to change findings with our assessment to limit disclosure to third party/insurance companies, or even

to spouses. Examine, if you will, the following scenario: client X comes on time for each session, follows through with all interventions, and is making progress. He then appears one day to ask us whether we could continue his treatment and bill the insurance company for the following year, even though his insurance will end shortly. Regarding disclosure, what do you do when treating a couple and the wife calls you after the fourth session to announce that she is having an affair with one of your colleagues? To “muddy the waters” just ever so slightly, the husband
announces that he suspects infidelity, but had been treated by another psychologist some time ago for jealousy. Yet other pitfalls lurk in the termination of therapy. Consider the clients who may perceive that they are being abandoned (just as their mother/father did); or clients who are not benefiting from our services but insist that they are; and finally, consider the clients who threaten us. To counter such pitfalls, I ensure that I outline a time limit, and that the client is in a collaborative, proactive role. As well, I explain the difference between abandonment and termination. Clients should be involved in the therapeutic plan from the onset. However, in spite of ethical measures and good intentions, the issue of competence and knowing how to terminate services when no longer needed or useful are not always apparent.

Confidentiality, competence, trust and “steering clear” of boundary violations might be managed with asking the following questions: whose needs are being served? Do I have sufficient skills to justify carrying this case? In forensic matters, am I utilizing appropriate tests? Interestingly, it is stated in research that problems in the area of the “slippery slope” occur more often with seasoned practitioners than with younger ones. Some possible reasons for this could be that, early in our career, we are overly careful and anxious to follow ethical guidelines; later the lines may not seem as clear. Navigating around difficult ethical issues may be easier if we ask ourselves whether we are giving more to a specific client or clients and why.

A final big question to ask ourselves is: are we respecting clients/therapist rights and responsibilities? Respecting the client’s autonomy and discussing at the outset the limits of confidentiality as well as our record keeping practice. In closing, vigilance and commonsense are paramount to avoiding conflicts between the ethics of psychology and the business of psychology.

Suggested Readings
Baur, S. The Intimate Hour: Love and Sex in Psychotherapy. Houghton Mifflin, 1997
Drake, R.E. and Deegan, P.E. Shared Decision Making Is an Ethical Imperative. Psychiatr. Serv 2009;60:1007 Aug. 2009
Sparta, S. and Koocher, G. Forensic Mental Health Assessment of Children and Adolescents. Oxford University Press, 2006

The Author
Joan Neehall, Ph.D., R.Psych. is a Registered Psychologist in private practice since 1984. She is the author of “Perfecting Your Private Practice”, 2004. She mentors new psychologists and leads workshops on the business aspect of psychology.