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Setting Clear and Ethical Boundaries with Clients

Section 15
Ethical Issues

Question 15 | Test | Table of Contents

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Let's look at how our judgments can create a conflict-of-interest. Actually, in some cases, judging has gotten a "bad name," so to speak, because it has been confused with the assigning of blame. Judgments, of course, are, however, an essential part of the therapeutic responsibility; And to be effective, our judgments must be made objectively and soundly and based on acceptance of the client.

♦ Exploring Your Judgments
Obviously to avoid a therapeutic conflict-of-interest, this requires that you make and use judgments, based on something more objective than your own personal value system. The personal value system boundary was discussed in great detail in the first section. We will now explore the specific component of your personal value system related to judgments. Exploration of your judgments requires what I call a two-sided reality based upon your two views...your view of your client and your view of the situation or context of your client's behavior. I will refer to these views as the individual view and the situational view.

You will note this corresponds with the first two steps in Robinson's ethical decision making process. If you recall Robinson's first two steps are: What is the context of the situation? and, What are my client's goals? followed by the question, Is there a potential harm? By looking at the context, we are looking at the larger picture; By looking at the client goals, we look at the smaller picture. Let's explore the smaller, or individual view, first.

♦ The Individual View
As you know, this individual perspective enables you to empathize with your client, to participate in your client's feelings and ideas without being a part of them, to understand how the client perceives him or herself and the situation, and how the client thinks and feels. In short, you are able to hear the "sound of your client's different drummer" to which he or she steps. This micro view is essential for an awareness of possible conflicts of interest, to understand and to reconcile similarities and discrepancies between your client's individual view and the larger picture.

For example in the case of a suicide risk...judgments regarding forced treatment, such as commitment to a hospital or placing the client under the constant care and surveillance of a significant other, violates much of the implicit and explicit contract boundaries and understandings between you and your client. Thus, the client's view is essential in assessing, for example, his or her fantasies associated with suicide. I have found, and perhaps you have too, that clients who have positive fantasies about their death may be more at risk for suicide than clients who have painful or difficult fantasies or no fantasies all.

♦ The Situational View
I treated a suicidal client, Karen, a mother who had painful fantasies that involved her children's lives should she commit suicide. Karen feared for their welfare after her death and had guilt about her consideration of suicide as a possible answer. Thus, my judgment regarding whether to commit her to an inpatient unit to prevent possible harm to herself was based upon looking at Karen's perspective versus the situation perspective.

My individual view was Karen's negative fantasy as it related to how she applied it to the larger view, or situational view, of her children. This caused me to make a judgment that she was not at risk for suicide. Thus, the conflict-of-interest related to the client's right to self-determination. My duty to protect from harm-to-self was resolved based on my judgment by evaluating Karen's perspective as it related to her fear for her children's well-being.

The larger view, as well as all its ramifications, needs to be perceived. Conflicts-of-interest can be ethically resolved by understanding the client and the client's behavior within the context and interrelationships of the total situation. As you know, how wide an area this view must encompass will depend on the situation that the therapist must comprehend and deal with in order to assist the client.

Thus, therapy judgments made on the basis of the correlation of individual versus societal frames of reference are much more likely to possess the objectivity, which is essential to avoid the unethical judgments and condemning activities that tend to inhibit the formation of effective relationships. In summary, the 2 Sides of Reality are:
-- 1.
Reality as it is, and
-- 2. The reality as the client sees it must be fully comprehended before the therapist can make a valid judgment.

- Robison, W. (2000). Ethical Decision Making. Boston: Allyn & Bacon.

Management of Ethical Issues and Conflicts of Interest

- Montgomery, P. R. & Still, E. D. (n.d.). Management of Ethical Issues and Conflicts of Interest. U.S. Department of Health & Human Services.

Peer-Reviewed Journal Article References:
Hague, C., Holland, A. A., & Gottlieb, M. (2019). Selected ethical issues in computerized cognitive training. Clinical Practice in Pediatric Psychology. Advance online publication.

Sah, S., & Feiler, D. (2020). Conflict of interest disclosure with high-quality advice: The disclosure penalty and the altruistic signal. Psychology, Public Policy, and Law, 26(1), 88–104. 

Samstag, L. (2012). Introduction to the special section on ethical issues in clinical writing. Psychotherapy, 49(1), 1–2.

QUESTION 15
What are the two sides of reality? To select and enter your answer go to Test.


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