A version of the following vignette was composed by a faculty member of the Georgia State University department of psychology:
Deborah, an intern at a university counseling center, has been working with a graduate student client for the past three months. The client, John, is in his early 30s and is ABD in the humanities. Deborah is pleased with the progress of the therapy, which has focused primarily on John's inability to move forward on his dissertation. Deborah suspects that John's academic difficulties are related to other areas of conflict, primarily having to do with his disappointment and anxiety over not having found a committed relationship during the five years he has been in his graduate program. John himself has recently introduced this theme into their work, and Deborah sees John's openness to such connections as a good prognostic indicator for an insight-oriented therapy.
Deborah's internship year is nearing an end, but she has accepted a postdoc at the counseling center and so will be able to continue working with John if he wishes to continue in therapy with her. It would also be possible for John to be transferred to one of the new interns. Deborah enjoys working with John and would be pleased to continue for her postdoc year.
Two weeks ago, John came into therapy and described to Deborah someone whom he'd met at a campus bar, who is also in the humanities although not in John's department. John was almost giddy as he described this person to Deborah, a feeling that Deborah has not seen John display before. John was pleased that this woman had agreed to go to a departmental lecture and reception this past week with him, and they have a date for the coming Saturday night. With a wink and a nod, John says to Deborah that he hopes the date will be an "all-nighter."
As John describes this woman whom he has just met, it becomes clear that he is almost certainly talking about a friend of Deborah's. At that moment Deborah recalls running into this friend at a coffee shop during the week, and her friend remarking in their passing interaction, "Things are good, I've met an interesting guy."
Can Deborah continue to treat John?
A more nuanced set of ethics
Campus counseling centers share features of rural settings, insofar as a close-knit group of colleagues serves a population with whom there are multiple and frequent occasions to interact in various, non-mental health-related roles. For this reason, opportunities often present themselves at college and university counseling centers for practicum students, interns and postdocs to develop ways of thinking about and addressing multiple relationships that arise in their lived, clinical experiences. Ideally, these encounters will move trainees beyond a purely textual understanding of our Ethics Code to a more nuanced and clinically driven set of ethics.
The concept of an Ethics Code driven primarily by our good clinical thinking is perhaps nowhere more evident than in Ethical Standard 3.05, on multiple relationships. After providing a definition, the code gives a test for when to refrain from entering a multiple relationship:
A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
Setting aside exploitation and harm, which do not seem prominent in the vignette, standard 3.05 poses a question for Deborah that is at heart a clinical question: Has an extra-therapeutic relationship begun to develop that presents a reasonable likelihood of impairment in her objectivity, competence or effectiveness as John's treating psychologist? Deborah and her supervisor will begin considering this ethics question with a discussion of John's psychological dynamics and the likely implications of his developing romantic interest for his psychotherapy. Their clinical discussion will drive their ethical analysis.
Deborah and her supervisor will assess the likely impact of John's new relationship on the therapy by exploring a variety of treatment-related factors. This discussion will be of the sort supervisors and supervisees customarily have throughout a clinical supervision, for example when they write treatment plans, respond to changing client circumstances relevant to treatment goals, or formulate plans for terminating or referring a client. Deborah and her supervisor might find it helpful to think through the situation with John and his new relationship as a graph shaded with the colors of a stop light: red, yellow and green.
Two salient features of the situation are the nature of the clinical work with John and the nature of Deborah's relationship with the person John has recently met. These features can be placed on the x and y axes, respectively, with greater intensity closer to the zero points. Because greater proximity to the intersection of the axes represents greater intensity, as one goes out on the x-axis the nature of the work with John becomes less intense, while as one goes farther out on the y-axis the relationship of John's new friend with Deborah becomes increasingly distant. One can then view the area under the curve that we may identify by color, from red (closest to the intersection of the axes), yellow (farther out) and green (farther out still, indicating a less intense treatment relationship and/or a lack of closeness or intimacy in the relationship between Deborah and John's new romantic interest).
Examining the graph will thus indicate three general areas. Red will indicate where there is a high likelihood of impairment in Deborah's objectivity, competence or effectiveness. Yellow will indicate where there is an elevated likelihood of impairment. Green will indicate where there is less likelihood that Deborah's objectivity, competence or effectiveness in working with John will be impaired. Deborah and her supervisor may find it helpful to plot where they believe the situation places Deborah in the red, yellow or green zones (and of course there will be shading, from bright red, where the intensity level on both axes is at its highest, to light green).
In the vignette, Deborah has been treating John for three months with the possibility of at least an additional year. Deborah believes that John is a good candidate for an "insight-oriented" psychotherapy, in which his relational life and the relationship between intimacy and work will undoubtedly be explored in some depth. John's "wink and nod" suggests a playful or perhaps even flirtatious attitude toward Deborah, which may also become part of the work of therapy. Taken together, these considerations suggest a point on the x-axis indicating a more rather than less intense treatment relationship with John.
The vignette provides little information about Deborah's relationship with John's new romantic interest. If Deborah and this individual are merely acquaintances with only passing familiarity, we will be farther out on the y-axis. Conversely, if theirs is a close, long-standing friendship, the point on the y-axis may be in much farther, indicating that Deborah is likely to be hearing intimate details about John from someone to whom she cannot disclose her treatment relationship.
This simple, although I hope not simplistic, device of depicting a standard 3.05 analysis on a graph, may be a useful aid in locating where a particular multiple relationship falls on a continuum. Should Deborah and her supervisor find using a graph helpful, they will explore the implications for Deborah's continued involvement in John's treatment on a plot in the red, yellow or green zone of the graph. Of course, there are no fixed dividing lines between these zones that apply across all psychologists and treatments; where a dividing line gets set will depend upon a variety of factors, such as the psychologist's way of working and comfort level, as well as community norms. A common factor, however, will be where the analysis starts: Excellent clinical judgment.
I would like to thank Sarah Dunn, who will be a psychology intern at Emory University, for calling this issue to the attention of "Ethics Rounds."
Stephen Behnke, JD, PhD, is director of APA's Ethics Office. Send questions, comments or suggestions regarding this column to Ethics Rounds.