Ethics in Psychotherapy and Counseling. Kenneth S. Pope

      Dr. Larson is an executive director and clinical chief of staff at the Golden Internship Health Maintenance Organization. For one year, he closely supervises an excellent postdoctoral intern, Dr. Marshall. The supervisee shows great potential, working with a range of patients who respond positively to her interventions. After completing her internship and becoming licensed, Dr. Marshall goes into business for herself, opening an office several blocks from Golden Internship Managed Care Organization. Before terminating her work at the organization, Dr. Larson tells Dr. Marshall that she must transfer all patients to other center therapists. All of the patients who can afford her fee schedule, however, decide to continue in therapy with Dr. Marshall at her new office. The patients who cannot afford Dr. Marshall’s fee schedule are assigned to new therapists at the center. Dr. Larson hires an attorney to take legal action against Dr. Marshall, asserting that she unethically exploited the health maintenance organization (HMO) by stealing patients and engaging in deceptive practices. He files formal complaints against her with the state licensing board, charging that she had refused to follow his supervision in regard to the patients and pointed out that he, as the clinical supervisor of this trainee, had been both clinically and legally responsible for the patients. He refuses to turn over the patients’ charts to Dr. Marshall or to certify to various associations to whom she has applied for membership that Dr. Marshall has successfully completed her postdoctoral internship.

      Dr. Marshall countersues, claiming that Dr. Larson is engaging in illegal restraint of trade and not acting in the patients’ best interests. The patients, she asserts, have formed an intense transference and an effective working alliance with her; to lose their therapist would be clinically damaging and not in their best interests. She files formal complaints against Dr. Larson with the licensing board, charging that his refusal to deliver copies of the patients’ charts and to certify that she completed the internship violates ethical and professional standards.

      Some of the patients sue the Golden Internship Managed Care Organization, Dr. Larson, and Dr. Marshall, charging that the conflict and the legal actions (in which their cases are put at issue without their consent) have been damaging to their therapy.

      THE FATAL DISEASE

      When George, a 19 year-old college student, began psychotherapy with Dr. Hightower, he told the doctor that he was suffering from a fatal disease. Two months into therapy, George felt that he trusted his therapist enough to tell her that the disease was AIDS (acquired immune deficiency syndrome).

During the next 18 months, much of the therapy focused on George’s losing battle with his illness and his preparations for the end of life. After two stays in the hospital for pneumonia, George informed Dr. Hightower that he knew he would not survive his next hospitalization. He had done independent research and talked with his physicians, and he was certain that, if pneumonia developed again, it would be fatal due to numerous complications and that it would likely be a long and painful death. George said that when that time came, he wanted to die in the off-campus apartment he had lived in since he came to college—not in the hospital. He would, when he felt himself getting sicker, take some illicitly obtained drugs that would ease him into death. Dr. Hightower tried to dissuade him from this plan, but George refused to discuss it and said that if Dr. Hightower continued to bring up the subject, he would quit therapy. Convinced that George would quit therapy rather than discuss his plan, Dr. Hightower decided that the best course of action was to offer caring and support—rather than confrontation and argument—to a patient who seemed to have only a few months to live.

      Four months later, Dr. Hightower was notified that George had taken his life. Within the next month, Dr. Hightower became the defendant in two civil suits. One suit, filed by George’s family, alleged that Dr. Hightower, aware that George was intending to take his own life, did not take reasonable and adequate steps to prevent the suicide, that she had not notified any third parties of the suicide plan, had not required George to get rid of the illicit drugs, and had not used hospitalization to prevent the suicide. The other suit was filed by a college student who had been George’s partner. The student alleged that Dr. Hightower, knowing that George had a partner and that he had a fatal sexually transmitted disease, had a duty to protect George’s partner. The partner alleged ignorance that George had been suffering from AIDS.

      LIFE IN CHAOS

      Mr. Alvarez, a 45 year-old professor of physics, has never before sought psychotherapy. He shows up for his first appointment with Dr. Brinks. He shares with Dr. Brinks that his life is in chaos. Dr. Brinks was granted full professor status about a year ago and about one month after that, his wife suddenly left him to live with another man. He became very depressed. About four months ago, he began to become anxious and to have trouble concentrating. He feels he needs someone to talk to so that he can figure out what happened. Mr. Alvarez and Dr. Brinks agree to meet twice every week for outpatient psychotherapy.

During the first few sessions, Mr. Alvarez says that he feels relieved that he can talk about his problems, but he remains very anxious. During the next few months, he begins talking about some traumatic experiences in his early childhood. He reports that he is having even more trouble concentrating. Dr. Brinks assures him that this is not surprising, that problems concentrating often become temporarily worse when a patient starts becoming aware of painful memories that had been repressed. She suggests that they begin meeting three times a week, and Mr. Alvarez agrees.

      One month later, Mr. Alvarez collapses, is rushed to the hospital, but is dead upon arrival. An autopsy reveals that a small but growing tumor had been pressing against a blood vessel in his brain. When the vessel burst, he died.

      Months after Mr. Alvarez’s death, Dr. Brinks is served notice that the licensing board is opening a formal case against her based upon a complaint filed by Mr. Alvarez’s relatives. Furthermore, she is being sued for malpractice. The licensing complaint and the malpractice suit allege that she was negligent in diagnosing Mr. Alvarez in that she had failed to take any step to rule out organic causes for Mr. Alvarez’s concentration difficulties, had not applied any of the principles and procedures of the profession of psychology to identify organic impairment, and had not referred Mr. Alvarez for evaluation by a neuropsychologist or to a physician for a cognitive and medical examination.

      LANGUAGE: THE INTERPRETER

      Angelica, who was born in Bolivia and migrated to the US two years ago, is a 55 year-old mother of three. Following the advice of her physician and sister, she decides to seek psychotherapy to deal with insomnia, lack of appetite, and uncontrollable crying spells. Angelica only speaks Spanish and there are no bilingual therapists available at the clinic; however, Dr. Jones agrees to work with Angelica. Wanting to help Angelica, Dr. Jones agreed to do therapy with an interpreter, although this is the first time she is providing therapy services with an interpreter. She is sure that all interpreters know what to do. Dr. Jones proceeds to schedule Angelic’s intake. During the clinical interview Angelica seemed to be worried and went back and forth with the interpreter. Dr. Jones, not speaking Spanish, is unable to follow what’s happening and when she inquires, the interpreter only says that Angelica feels ashamed of speaking about her family’s business. Dr. Jones, via the interpreter, tells Angelica not to worry and goes on to discuss informed consent and confidentiality. Angelica does not return to her second session and several months later, Dr. Jones receives a letter indicating that a civil law suit had been filed against her. According to the letter, Dr. Jones assured Angelica that all of the information that was shared in therapy would remain confidential, but somehow her husband, who has a long history of domestic violence, found out all of the details that Angelica disclosed to Dr. Jones during the intake interview. He became so violent toward Angelica that she spent several days in the intensive care unite (ICU) recuperating from the physical abuse.

COMPUTER COINCIDENCES

      What happened to these therapists was so traumatic that, even though they are fictional characters and never existed, they have fled into other lines of work, do not want to be recognized, and demand anonymity in this hypothetical scenario. The catastrophes seemed to start