Daily Archives: November 4, 2010

Slippery Slopes and Dual Relationships


In debate or rhetoric, a “slippery slope” argument is known as an informal fallacy.  The argument suggests that a relatively small first step inevitably leads to a chain of related events culminating in some (generally undesirable) significant impact, in this case, a severe boundary violation.  (Fischer, 1970)  “The mere existence of a multiple relationship does not, in itself, constitute malpractice; rather, it is misusing power, harming, or exploiting a client that is unethical.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 269)  The suggestion that the mere existence of a dual relationship leads to severe boundary violations is an unsubstantiated causal relationship.  However, the correlation is made because severe boundary violations can and do happen, and inevitably they can coexist with multiple relationships.

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Every therapist can probably relate to having friends that talk about their problems.  I already play that informal role with a number of my friends and family (e.g. confidant, advisor).  Generally speaking, it is probably fair to say that I should not engage in professional therapeutic relationships with these friends or family members.  The definition of “formal” is one with a good deal of ambiguity however… I would be inclined to define it as “anyone who pays for my services or comes to the office for the visit.”  I anticipate I will have difficulty “shutting down” my therapeutic mind when placed in that informal role.  Within that context, there is potential for a bit of a “slippery slope.”

Another possible dual role I can anticipate is that of a court appointed evaluator.  In this situation, once I have assumed that role (with the court as my client) I cannot then assume a role as a therapist for the same client.  In that situation, I will likely need to refer the client to another primary therapist.

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References

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th ed.). Belmont, CA: Brooks/Cole.

Fischer, D. H. (1970). Historians’ fallacies: Toward a logic of historical thought. New York, NY: Harper & Row.

 

Physical Contact with Clients


What are your beliefs about physical contact with clients?  What questions should you ask yourself before engaging in physical contact?  How do you know when it is not a good idea?  What are some of the potential negative outcomes?  How do these risks and benefits weigh out?

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My beliefs regarding physical contact with clients are “mixed.”  Although I can certainly see benefits in some situations (increased sense of empathy), I see some serious risks as well (misinterpretation of the action, dependency).  I am not a “touchy feely” person by nature, so this isn’t something I anticipate having huge issues with.  I am innately more likely not to touch someone “non-erotically.”  I would probably err on the side of caution for no other reason than “that’s the way I am.”  Although I do have a desire to convey caring and compassion, I honestly don’t feel like I need to touch someone to convey that.

There are a number of questions I would need to ask myself before I would ever consider touching someone.  Gender… if I wouldn’t touch someone of the opposite sex of the client in that situation, I probably wouldn’t do it at all.  Age… honestly, I would be more comfortable hugging someone who was elderly than I would someone who was younger than me.  I would consider the current diagnosis of the client, especially any history of sexual or physical abuse.  If any history of abuse is present, including being raped, molested, sexual addictions or intimacy issues… it’s probably a safe bet not to touch them.  I would also be very careful with paranoid or borderline personalities as it has real potential to evoke a negative response.

Also, I would consider the context of the therapeutic relationship… if it is individual therapy in a private practice setting I would be much more cautious than if it were in a group setting.  I would also need to consider the length and the level of trust that has been established with a client.  I would be much more inclined to touch someone if we had discussed the issue previously, or if we had a long standing therapeutic relationship/alliance.  In any case, I would probably ask the client if it is ok with them if I touch their hand, etc.

I would consider the potential benefits of such an action, weighing my personal motivations and potential interpretations on the part of the client.  All touch is reciprocal – one cannot touch without being touched… and I’m just not comfortable with touching.  I agree with the text that if touching occurs, it should be a “spontaneous and honest expression of the therapist’s feelings and always done for the client’s benefit.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 316)

In any event, documentation of the type and frequency of touch, along with my personal rationale for employing it, is critical.  This is increasingly important if touching is subsequently misinterpreted and a malpractice lawsuit is levied.  Perception is reality for clients, and what is considered “appropriate” to me may not be “appropriate” to the client.  Another potential negative outcome could be pre-mature termination.  If the client is no longer comfortable with the clinician as a result of non-erotic touching, more harm has been done than good.

In conclusion, I think the risks outweigh the benefits in most situations.  It’s not that I consider it taboo or anything, I just don’t think I need to touch someone in order to convey caring, sensitivity, or understanding.  I can convey warmth and empathy with my voice.  My aversion to touching clients has less to do with the potential negative outcomes than it does with my belief that other methods are as effective or more effective.  If we drill down to a point where a client is crying and in obvious distress, I am of the belief that a certain degree of distress is healthy.  Touching a client provides a false sense of security in my opinion, premature resolution, and a certain sense of dependence.  In as much as I am there to help a client, I am there to promote independence, not dependence on the clinician.  In more ways than one it has the potential to be counterproductive for the client, and for that reason, I am going to use touch very judiciously.

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Reference

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th ed.). Belmont, CA: Brooks/Cole.

 

Family Therapy Confidentiality


Although there are differing perspectives on how secrets should be handled within the context of family therapy, my personal perspective is that the family should have visibility into the individual sessions.  Essentially, anything said during an individual session is subject to being included in family therapy.  Inherent in this perspective is the assumption that this is fully disclosed and discussed in the process of informed consent, so that all members of the family understand the concept.  This perspective comes with both benefits and with drawbacks.

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There are some situations where I suspect an individual would not disclose information in an individual session where they might have otherwise.  An extra marital affair is one such example.  With my personal framework and expectations, the individual may not want to disclose such information with me in individual sessions due to the fact that I would admittedly introduce that subject up in the family session.  The end result is a perpetuation of the secret, and the therapist being “cut out of the loop” on individual secrets.

I believe the benefit is that it adds transparency into the family therapy environment.  I believe a foundation of trust and mutual respect is the foundation on which a family should be built, and as a result, there should be few if any secrets.  One party (the husband, for example) can have confidence in allowing his wife to engage in individual therapy with me because he understands that relevant findings will be brought to the attention of the entire family.  In any case, I would implement this policy because I believe the very act of keeping the secret is an act of collusion.  I agree with the text that this policy is liberating in the respect that it frees me, as a therapist, from being put in the position of keeping a secret of a client participating in conjoint therapy.  I think the situation of having to keep a secret is best avoided entirely with by establishing a framework of transparency from the outset.

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