Recently "Ethics Rounds" received the following vignette and question:
Several weeks ago, Dr. Alby began treating Kevin, who is 14 years old. The focus of treatment has been to assist Kevin in working through the loss of his biological father, who following a separation has not been living with Kevin and his mother for about a year. Kevin's father has little involvement or apparent interest in Kevin's life. At present, Kevin has a number of somatic complaints and appears to be experiencing a mild depression. He has recently engaged in some antisocial behavior (shoplifting and staying out past his curfew), which seems consistent with a "bad boy" persona that he is adopting. He reports not being happy in school and is not doing particularly well. Thus far a positive and productive relationship between Dr. Alby and Kevin seems to be developing, which Dr. Alby finds encouraging.
Kevin began a recent session by reporting that his mother is considering enrolling him in Bay Bridge Academy, a nearby private school that has an excellent reputation and is known especially for its small class size and the involvement of parents in both curricular and extracurricular activities. As Dr. Alby was listening to the material, he could feel his chest tighten. Wendy, his 14-year-old daughter, is a student at Bay Bridge and involvement in her school activities is the source of great pleasure and pride for Dr. Alby.
Is Dr. Alby in an ethical dilemma?
This vignette is a wonderful example (from the perspective of the observer, that is) of when a psychologist, without warning and without any contributing behavior on the part of the psychologist, is suddenly confronted with the possibility of entering a multiple relationship. There is not the slightest suggestion that Dr. Alby has engaged in unethical behavior. From the vignette, he appears to be a good therapist and a good father. Should the situation evolve into a multiple relationship-we don't know yet that it will-Dr. Alby will find himself in this challenging position not because his behavior is ethically problematic but rather because Dr. Alby is involved with his child and has welcomed and embraced an opportunity to participate in her school experience.
APA Ethics Code, Ethical Standard 3.05: Multiple Relationships
(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
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.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.
The physical sensation Dr. Alby experienced during the session might be a good place to begin exploring the ethical aspects of his situation. This sensation, which Dr. Alby notices, is likely a sign of some underlying anxiety that he is experiencing, what some psychoanalysts would refer to as the countertransference. A feeling, as much as a thought, can be the sign of an unspoken ethical concern and we can begin by wondering what may be making Dr. Alby anxious.
In pondering Dr. Alby's anxiety, it is helpful to recognize that at this point his experience is one of anticipatory anxiety; nothing has yet happened. Thus, Dr. Alby's anxiety is a signal of concern that something may happen in the future. It will be fruitful for Dr. Alby to sit and consider what possibilities are weighing on his mind.
The vignette offers multiple possibilities, ranging from relatively straightforward and benign to quite complicated. Assuming that Kevin does apply, is admitted and chooses to attend Bay Bridge, his presence at the school will likely mean that he and Dr. Alby will have incidental contact at the very least. Contact of this nature, while not without its complexities, may afford Dr. Alby and Kevin an opportunity to deepen their work by talking explicitly about their relationship in the context of extra-therapeutic encounters. If Dr. Alby broaches the subject in a collaborative way, "Let's talk about how you and I are going to make this work," Kevin may feel taken seriously and respected. The collaboration may also be helpful in allaying Dr. Alby's anxiety that he bears full responsibility for the treatment. While Dr. Alby is responsible for making good, ethical decisions, both he and Kevin bear responsibility for how their relationship evolves. This possibility provides each an opportunity to embrace and share that responsibility.
Dr. Alby may have much more complex possibilities in mind. Given the size of the school and the culture of parental involvement, Dr. Alby may be contemplating the possibility of supervising extracurricular, perhaps overnight or weekend activities that include Kevin. He may even be considering the possibility of Kevin and his daughter developing a social or dating relationship. These possibilities will-or will not-evolve over time.
If Kevin does transfer to Bay Bridge, Dr. Alby will inevitably face both challenges and opportunities in their evolving relationship. Dr. Alby may then choose to consult with a colleague. A consultant will help Dr. Alby make best use of the opportunities and avoid pitfalls that, in the words of Ethical Standard 3.05, "could reasonably be expected to impair [Dr. Alby's] objectivity, competence, or effectiveness in performing his functions as a psychologist." If it appears to Dr. Alby and the consultant that developments in the relationship with Kevin make such impairment reasonably likely, Dr. Alby may choose to refer Kevin to another treater. Ideally, Kevin will be very much a part of that decision-making process. Of course, both in considering whether to refer and in the referral process itself, Dr. Alby will be mindful of Kevin's history with his biological father.
Our discussion has assumed that Dr. Alby's experience during the session is one of anxiety. While a reasonable conjecture, we can't be certain. Perhaps he is rather feeling annoyance that a client is intruding upon his personal life. By attending to his physical experience and allowing himself to explore that feeling, Dr. Alby will be in a better position to differentiate his experience and his needs from those of his client. Ideally that differentiation and awareness will make it less likely that Dr. Alby will allow his feelings to have a poorly understood and negative effect on his professional work.
There are moments in every psychologist's professional life that are fraught with anxiety about what is to come. Sometimes it is best not to act, but rather to sit with our experience and explore what we can learn from our feelings. As situations evolve, it can also be helpful to remain mindful that we are not alone. We can collaborate with our colleagues as consultants. Often, it can be enormously valuable-and anxiety-reducing-to collaborate with our clients as well.
Send questions, comments or suggestions regarding "Ethics Rounds"-or submit vignettes (without identifying information) for column discussion-to e-mail. "Ethics Rounds" welcomes your involvement and will confer with authors before publishing letters to discuss any confidentiality concerns and edit the material accordingly. Previous "Ethics Rounds" columns can be found at APA Ethics in the "From the Director" section.