Common Dilemmas in Couple Therapy

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Sometimes good clients do bad things. Other times, however, the rules are a little grey. This is especially common for social workers who are working with clients who are incarcerated or abusing drugs.

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Ten years ago it was considered unethical to email our clients. Now our Code of Ethics specifically addresses the best practices for conducting therapeutic services over the internet. One issue that remains sticky is social media. There is no easy answer, and sometimes there is no right answer. Spend some time reading through the code. Identify the principles that come into conflict in the specific situation and why they are important to social work practice.

Be sure your decisions are sound, not only ethically but legally. Everyone needs a second opinion once in a while.

Ethics & Malpractice

Supervisors can be particularly helpful in guiding you to make the best decision possible in a difficult situation. One of the most vital benefits to being a member of the NASW is having the support of a national organization to back up your work. Most states have a hotline social workers can call when they experience ethical dilemmas. You can discuss your situation confidentially, without using identifying client details, and get professional advice on how to handle things.

Sometimes a neutral party is the best resource to help you consider things from a new perspective. At the end of the day, you need to be able to live with your decision and to feel confident you are doing what is in the best interest of your client. Integrity — Part of our job is to serve as role-models by maintaining healthy and appropriate boundaries in professional relationships.

Involuntary Commitment Regardless of your social worker breed, at some point you will come across a client who intends to harm himself or someone else. It is not uncommon with some treatment approaches such as EMDR or Bioenergetics for therapists to attempt to begin using the techniques before completing the entire training. Over the last several years as managed care has become more a part of a practicing psychotherapist's life, there has also been a rise in allegations that therapists are deliberately reporting diagnosis to insurance companies that are not accurate to trigger coverage where it should not exist.

For example, it is not uncommon to have an allegation that a therapist failed to disclose an Axis II diagnosis because of an awareness that a particular insurance carrier in question would not cover any such condition. The general rule is that the diagnosis for treatment and diagnosis for insurance should be the same. The law does not recognize or permit the therapist to have one diagnosis for treatment purposes and one diagnosis for billing or insurance purposes.

In fact, the existence of two such diagnosis offers an opposing attorney a great opportunity to impugn the therapist's credibility. A patient should only be diagnosed with the accurate diagnosis. A typical scenario is for a therapist to report a less severe diagnosis, such as adjustment disorder, rather than a dissociative disorder, or if the patient has a borderline personality disorder. When some dispute arises and the therapist wants to assert that the patient has the more severe diagnosis, that was not actually used in reports to insurance companies, the patient's attorney or the attorney for the licensing board will probably contend that the more severe diagnosis was made up after the dispute arose, because no preexisting record can be found.

Faced with the complexities of informed consent, standard of care, note taking, etc.

Malpractice Pitfalls for Therapists

This has the same effectiveness as reporting to the Internal Revenue service that you do not believe that the tax laws are valid, and that you should not have to comply with them. While this may lead to making the acquaintance of interesting criminal defense and bankruptcy lawyers, it will not cause any change in the IRS's view of the applicability of the tax laws. By the same token, for a psychotherapist to assert that he or she should not be subject to the medical model will be ineffective.

The medical model will generally be imposed with or without your agreement. Over the years some therapists have sought to invoke the "true love" exception to actions for damages or by licensing boards arising from sexual relationships with present or former patients. There is no true love exception, there never has been a true love exception, and, in all probability, there never will be a true love exception. Sexual relationships with existing or former patients are unethical under most associations' ethical principles, illegal in some states such as California , and have career killing consequences.

It is almost axiomatic that what is seen as true love at the time the relationship begins is seen as mishandling of transference after the relationship ends. An example of this attitude is a survey of psychiatrists from The study involved over 1, psychiatrists, and approximately Approximately The issue of whether the relationship was due to "true love" was a factor for some of the respondents. Under no circumstances should and therapist seriously consider a sexual relationship with a present or former patient regardless of how long the interval has been between the termination of the patient and the beginning of the relationship.

Generally a therapist who is choosing to engage in such a relationship with a patient is effectively choosing to discard his or her career.


A continuing issue has been the failure of therapists to take accurate notes and, in some cases, any notes at all. While some experts may still say that there is a wide variance in the practice of therapists over keeping notes, the practical fact is that notes are essential for survival in this litigious age.

Notes should not only be accurate, but should be meaningful in terms of content. The notes should indicate what was said by the patient, as precisely as possible, and what the therapist did or said about the patient's communication.

It is not necessary that the notes be written in plain English, but the notes should be an accurate picture of what was discussed. A therapist should never agree to not take notes at a patient's request. In fact, such a request from a patient should cause the therapist to seriously questions whether the patient has a secondary agenda.

A related issue to failure to take notes is the failure to obtain an adequate history.

Learning Objectives

It is a common practice for licensing boards and civil plaintiffs to focus on the patient's history, to have the context of making an accurate diagnosis. The assertion that a therapist failed to obtain an adequate history is a common one, and in some instances is justified. An expert in civil litigation and for licensing boards, Dr. Jeffrey Younggren, has commented that therapists, in addition to being required to comply with the standard of care, must utilize common sense in weighing what patients tell them.

The various cases that have dealt with repressed memory issues have articulated what amounts to a duty to utilize common sense or critical judgment, or a duty to be skeptical of a patient's implausible memories.

Malpractice & Licensing Pitfalls for Therapists: A Defense Attorney's List

To uncritically accept implausible memories of sexual abuse has been found to be below the standard of care by the California Board of Psychology. As early as September of Dr. There have been a proliferation of such syndromes over the last several years. At this point using syndromes which are not appropriately researched or acknowledged by the profession is below the standard of care. Among the syndromes which are controversial and which should not be represented as accepted in the therapist community are Child Sexual Abuse Accommodation Syndrome, Parental Alienation Syndrome, [ Wiederholt v.

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Fischer WIS 2d , 45 N. As a general rule, unless there is a specific therapeutic purpose for it, patients should only be seen in the therapist's office.