"Ethics Rounds" received a letter, excerpts of which are below, from a man who lost a sibling in a tragedy felt acutely by our entire nation. The author, who has achieved a significant measure of professional success, witnessed the tragedy that led to his brother's death and sought treatment when he recognized that he himself was experiencing symptoms of post-traumatic stress disorder for which he was encouraging his employees to seek therapy. Subsequently, the author's wife requested a referral from his psychologist/psychoanalyst, and began her own intensive work with one of the recommended therapists, a psychiatrist. Well into the treatment, a fact emerged about their now treating therapists that had neither been discussed nor disclosed at the time of the referral or after: The treating psychologist and psychiatrist, who did not share a last name, were married. The author writes:
Betrayal, distrust and lack of intimacy are among other issues I've been dealing with.…My trust has been shattered. The shock and betrayal I feel at the failure to disclose this information has led me, after three confrontational sessions, to terminate my therapy.…The deception and manipulation I feel are overwhelming. I am enraged that two very smart, highly skilled and experienced professionals could have conspired to collectively make such a horrific decision. I believe I had a right to know. Looking back on previous sessions, I believe there were several times when information that I shared in confidence was leaked "over the kitchen table" and used in my wife's therapy. It appears clear to me that both therapies have been contaminated for some time. After my wife confronted her therapist first, it's clear that he "warned" his wife when I came to my next session….I find the action of our therapists unconscionable and thoughtless, especially about the possible consequences to me.
People bring us their pain. That represents a great privilege and a great responsibility for our profession. The human condition is such that we cannot always take pain away. While our clients will forgive us much, they will not forgive our causing them more pain by failing to apply our clinical skills in thoughtful, competent and respectful ways.
Driving our ethics are the twin values of beneficence and nonmaleficence, which form Principle A of the Ethical Principles of Psychologists and Code of Conduct, "Psychologists strive to benefit those with whom they work and take care to do no harm." By virtue of the complexity of our work and the influence that we have over people's lives, harm can easily come from failing to think carefully through how our decisions affect our clients, rather than from untoward intentions.
The unique role and relation we have with our clients give psychology its own ethics, so that being an ethical psychologist is not the same as being an ethical person. What makes our role and relations as psychologists unique from an ethical perspective is that they are based upon trust. A foundation central to that trust is that psychologists will apply their clinical skills in a manner that guards against possibilities of unnecessarily causing further pain.
The pain in this man's letter is palpable. As he describes it, a trust broken by his therapist has made the pain he brought to treatment more acute. At the heart of that broken trust is what he appears to experience as insensitivity to how his relationship with his treating psychologist evoked pain from past relationships. Exacerbating his distress is that a disclosure and a discussion initiated by his psychologist may have helped avoid the rupture in the therapy relationship that he has found so upsetting. Relatively simple and straightforward language can address the issue in a direct and helpful way: "I have someone who I think would be especially good, although we first need to talk about this person's relationship to me, which could complicate matters in our work together…," or some similar wording.
To accept that something very painful occurred in the treatment, one need not assume that these treaters were acting from problematic intentions. One could assume the very opposite, that their motivations were entirely appropriate and ethical. Being good at what one does and being passionate about one's work can be a hugely attractive quality in a person, and we often love and commit ourselves to people whom we admire in part for these very reasons. It is therefore not in any manner surprising that psychologists sometimes feel inclined to refer to people with whom they have committed relationships. That understandable inclination becomes problematic when psychologists do not assume responsibility for thinking through its implications in a careful process, a process that should address at least three issues.
First, a potential dilemma arises out of the principle of beneficence, by virtue of which we strive to do good, insofar as referring a therapy client to someone with whom we share an intimate relationship may also accrue to our financial benefit.
Ethical Standard 3.06, Conflict of Interest
Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation.
Disclosure is sometimes seen as a remedy to a conflict of interest. When a spouse or partner to whom a treating psychologist refers does not share the psychologist's last name, the client does not have a cue even to raise the question. In this instance, a failure to disclose, coupled with the potential conflict of interest, risks an especially complicated clinical effect should this information emerge in the course of the therapy or after.
Second, clients often have fantasies about how we handle their confidential information. Proximity to and contact with important figures in our clients' lives can be related to how intensely they concern themselves with matters of confidentiality. When a psychologist does not disclose information that a client may very reasonably believe is important, what is shared and what is not-who gets told what-will inevitably be part of that treatment. In a case of married psychologists treating a husband and a wife, the power of the clients' fantasies regarding what is being shared may overshadow the reality. At the very least, each psychologist will need to make clear that treatment-related information will be shared only with explicit permission and only then after careful discussion. Even with such caveats and complete abstinence from inappropriate disclosures, the concern over confidentiality may significantly complicate one or both treatments. The difficulty in allaying these concerns is understandable when placed in a larger context; protecting spousal communications with testimonial privilege is society's way of formally recognizing the unique and intimate communications that occur between spouses.
Third, many clients will seek to please or at least seek to avoid disappointing their therapists. A referral to a treating psychologist's spouse, whether disclosed at the time of the referral or subsequently discovered, will inevitably provoke complicated and ambivalent feelings that will need to be addressed in the course of treatment. The clearest statement up front that a client is free to pursue the referral, or not, as he may wish, may help diminish how the client experiences these feelings but will almost certainly not remove the necessity of addressing the issue at some point. The stakes for everyone involved are simply too high. The referral is to perhaps the most intimate person in the referring therapist's life so that any decision the client makes will be fraught with meaning-which will be outside the awareness of very few clients.
Special considerations for how to handle these situations arise in rural areas, but the author of our letter writes from a city rich in psychology resources. Wherever treating psychologists find themselves facing ethical dilemmas, benefiting those with whom we work and protecting their welfare call for engaging in a thoughtful process that will lead to an ethical course of action. Reflecting on our own motivations-regarding the letter above, what reasons we might give for not disclosing such a relationship-and engaging our clients in a process of informed consent can be excellent places to begin. Our clients bring us enough of their own pain. The principle of nonmaleficence-do no harm-calls us to avoid adding to their pain, at the very least through the competent application of our professional skills, expertise and knowledge.
In a part of his letter not printed above, the author writes that he pursues this matter solely in the hope that someone else will be spared his distress. To that end, "Ethics Rounds" thanks the author for allowing his experience to be shared in a public way.
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Previous "Ethics Rounds" columns can be found at APA Ethics, in the "From the Director" section.