1. Dr. Z. is a licensed psychologist in private practice. He is approached by his ex-wife’s friend who wants to see him for psychotherapy. Discuss whether it would be ethical for Dr. Z. to accept this person as a patient.
ANSWER: Dubious and depends on whether Dr. Z. will be able to use independent judgment. The hypothetical does not describe the nature of the friendship between the proposed client and Dr. Z.’s ex-wife. If they are not close and it simply is a casual referral then it is less problematic. On the other hand if they are close or intimate friends then it is unlikely Dr. Z. will be able to maintain an appropriate professional boundary. His personal feelings may cloud his judgment and interfere with the therapeutic process. The client also may know things about him as a result of communication with his ex-wife, which further would complicate matters and make it less likely the client would achieve a beneficial outcome. If I were Dr. Z. I would assess the situation carefully on intake. If there were any hint of a boundary issue then I would refer the proposed client to somebody else who was qualified in the field.
2. In order to keep his overhead expenses low Dr. Z. does not renew his office lease and instead starts to treat patients in his house. In light of ethical standards is this an appropriate arrangement? Why or why not?
ANSWER: Dubious, although this increasingly is practiced for economic reasons. The reason why is the client may become confused and view the therapist as a social colleague rather than as trained professional. Items such as photographs, memorabilia or even religious artifacts may populate a personal environment. These would be disclosed unnecessarily to the client, complicating the therapeutic relationship. They may provoke transference-like reactions from the client. If I was Dr. Z. it’s not clear to me I’d want the client to know where I lived. A better alternative would be for Dr. Z. to sub-lease a colleague’s space, if only on a session-by-session basis.
3. Dr. Z. decides he wants to extend his practice to treating children. He never has had any training in child psychotherapy but begins to read books on child psychology. He also starts seeing children for therapy and advertises himself as a child psychologist. Is Dr. Z. acting ethically? Why or why not?
ANSWER: No. Dr. Z. lacks competency in a specialized area. Separate training and clinical experience are necessary to qualify one to administer therapy in fields outside of one’s core background. Dr. Z. may miss important issues or misinterpret or misdiagnose those he is able to identify. For example the child may have medical problems such as dyslexia impeding an overall positive outcome. An interdisciplinary approach might provide better results. While advertising is not unethical per se it is an actionable misrepresentation for Dr. Z. to hold himself out as a specialist in a particular field, when in fact he is not.
4. After working with children for two months Dr. Z. finds himself bored when he is in session with his child patients. What would be the most ethical course(s) of action for him to take?
ANSWER: Dr. Z.’s primary client is the children whom he is seeing although their parents are “adjunctive participants” and Dr. Z. owes them a legal duty. They are the childrens’ legal guardians and have a right to know about issues affecting the progress of therapy. In this case Dr. Z. no longer can be objective or act in a proper clinical role. He might consider discussing the issue with the parents, although this most likely would be unproductive or even counter-productive because it would call into question the extent of his commitment to the therapeutic process to date. There is no indication the goals of therapy have been met. On-going therapy still is required, but it has to be done by somebody other than Dr. Z. Dr. Z. should use appropriate termination procedures and refer to another qualified therapist. A good guideline for Dr. Z. to follow might be: “If I was a parent, would I want to know this?” Here I think the answer clearly is “yes.”
5. Dr. Z.’s new patient tells him she was referred by her employer because of disruptive behavior at work such as arguing with colleagues and raising her voice. She adds her supervisor told her she would be terminated if she does not attend therapy. After his initial session with this patient Dr. Z. decides it would be a good idea for him to talk to his patient’s supervisor to better understand why she was referred for treatment. Discuss whether it would be appropriate for Dr. Z. to contact his patient’s employer.
ANSWER: If he did so Dr. Z. would be breaching his obligations of confidentiality, unless he first obtained a proper medical release form from his client. It is not unusual for an employer to refer an employee to therapy. However the employee is the therapist’s client, not the employer. The results and outcomes of the therapy are confidential. It is an ethical violation for a therapist to disclose confidential information and also a violation of Federal law (the HIPPA statute). Even if Dr. Z. determines such a consult is in the client’s best interests he should apprise the client of possible consequences to insure informed consent. For example even though it also is against Federal law for the employer to retaliate against the employee by demoting or firing her, she may become the victim of tacit or subtle discrimination at work that cannot otherwise be identified or recompensed.
6. Dr. Z. has been treating a patient diagnosed with Major Depressive Disorder. After the fifth session Dr. Z. discovers the patient’s insurance company has authorized only six sessions for therapy. In order to behave ethically what should Dr. Z. do in this situation?
ANSWER: Dr. Z. has mistimed the administration of therapy. He should have discerned the scope of insurance coverage on initial intake. This would have enabled him to modulate his therapeutic approach in order to maximize the likelihood of benefit to the client. MDD is a serious Axis I pathology. It is likely the client may suffer adverse consequences if therapy simply terminates. Dr. Z. should contact the insurance company and make a case for further therapy. He might consider offering his services on a reduced-fee or even a pro bono basis, although there is no ethical requirement he do so. Doing so might be impermissible under the provisions of the client’s insurance. It also might jeopardize Dr. Z.’s perception of his duties to his other fee-paying patients, i.e. he might come to favor or prefer them more in a variety of subtle ways to this client’s disadvantage. Dr. Z.’s best alternative is to refer this client to a low-fee or public service agency, which can accommodate the client’s needs and requirements within the scope of the client’s budget.
7. Dr. Z. has been treating a middle-aged man with relationship problems. Dr. Z. finds he identifies with his patient’s situation on a personal level and often thinks about his own relationship issues when in session with this patient. It recently occurred to Dr. Z. he would enjoy being this patient’s friend. To ensure he behaves ethically what steps (if any) should Dr. Z. take?
ANSWER: Dr. Z. is confusing his role with the client. He is the client’s therapist, not the client’s friend. The conventional duties and benefits of friendship based on social exchange are completely different than the professional requirements of being a therapist. Dr. Z. is permitting his personal feelings to cloud his professional judgment. His therapeutic approach and techniques may be affected. This inevitably will disadvantage the client. The client is seeking psychotherapy, not a social friend. I do not know if there is any scenario under which Dr. Z. can properly terminate therapy and become the client’s “friend.” While he can do the former it is difficult to see how he could accomplish the latter. He still would be under obligations of client confidentiality and non-disclosure. He still might view the former client as an actual client, and vice versa, to the client’s detriment. At the very least a considerable length of time would have to elapse before Dr. Z. and his ex-client properly could establish a social relationship.
Dr. Z. also is experiencing a form of counter-transference. While it may not be uncommon for a therapist’s mind to wander during the course of a session one of the basic duties of the therapist is to concentrate on what the client is saying. It per se is impossible for a therapist to administer any form of therapy if he isn’t paying attention. Dr. Z. might consider discussing this problem with the client, though if he does so he runs the risk of making the therapy “about him” instead of “about the client,” which is not in the client’s best interests. On the whole termination is the better course of action.
8. In December one of Dr. Z.’s patients gives him a card wishing him a happy new year, which Dr. Z. accepts. Yet another patient brings him a holiday gift. Would it be ethical for Dr. Z. to accept this gift?
ANSWER: It depends. A New Year’s card is uncontroversial and absent unusual circumstances Dr. Z. simply should accept it as a matter of conventional inter-personal niceties. The same thing is true of a “holiday gift” provided it has minimal value and the client’s intent simply is to acknowledge the spirit of the holiday. There is no indication in the hypothetical it was given out-of-context, with some covert motive, with any expectation of reciprocity or with the prospect of secondary gain. It is timed appropriately. The gift may have symbolic significance to the client arising out of the therapeutic relationship; in some circumstances it even may be a kind of “transitional object.” It may be an expression of appreciation or gratitude and in this sense enhance the therapeutic alliance. Conversely the client may feel rejected (for cultural or personal reasons) if Dr. Z. doesn’t accept the gift. Dr. Z. might consider exploring with the client the reasons why the client has proffered the gift. In the event Dr. Z. is in doubt he should consult with a supervisor or colleague and document the transaction in his clinical notes. The goal of therapy is not for the therapist to “become the client’s friend.” This being so if not over-interpreted the incident described in the hypothetical should not present an ethical issue and Dr. Z. simply needs to exercise good judgment.
9. Dr. Z. has been treating a man in his early 20’s. This patient asks him many questions, for example, he wants to know about Dr. Z.’s professional background and his personal life. How should Dr. Z. respond to these questions?
ANSWER: Guardedly. According to classic Freudian theory the psychoanalyst should say nothing and possibly not even be seen by the client during the course of a session so as not to interfere with the client’s free association process and the development and resolution of a transference neurosis. This stance came to be discarded with the advent of Rogerian therapy in the 1960s. Rogers held two people are in congruence if they are at the same level of discourse, i.e. one isn’t pretending to be more knowledgeable, or an authority figure, or in a dominant power relationship, over the other. When the therapist is in congruence with the client, she is capable of empathetic listening and supplying unconditional positive regard. The client feels understood and the therapist radiates this feeling of being understood back to the client. This last component is crucial. Without it the client lacks evidence her communication to the therapist has been successfully received. In supplying this evidence it is appropriate for the therapist to draw analogies from her own experience. Thus, the therapist might say something like: “I understand what you are saying. You are saying (briefly reparse what client said). The reason why I understand it is because (brief self-disclosure by therapist).”
This being so the nature, scope and extent of self-disclosure depend on the texture, caliber and quality of the therapeutic relationship, including factors such as the client’s age and psychological condition. Disclosures regarding the therapist’s background and training are permitted as are (self-obvious) ones regarding to age, ethnicity and brief biographical details (such as whether one has children). In some contexts such as addiction therapy the client may not believe the therapist is credible unless the therapist has had (and discloses) hands-on experience with the subject matter. The therapist should not offer soliloquies, deal with bizarre topics or explore tangents that would disconcert the patient (e.g. a discourse on her favorite color, or religious subjects). A good litmus test is for the therapist to say: “What makes you ask?” in response to client inquiries, which should provoke further useful dialog.
10. Dr. Z. administers an MMPI-2 to a Chilean man who obtains elevations on scales 1 and 3 and a low score on scale 5. Considering this man’s background what are some possible interpretive hypotheses for his MMPI-2 profile?
ANSWER: Scale 1 is hypochondriasis (Hs); scale 3 is hysteria (Hy); and scale 5 is masculinity-femininity (Mf). MMPI-2 clinical scales are interpretable only if the t-score is ≥ 65 (so I assume this is what “elevated” means). Generally Hs measures somatic concerns or delusions. A high-endorser typically lacks energy, is whiny and dissatisfied, may be demanding or complaining and suffers from sleep disturbances. Hy was developed to identify persons who have hysterical reactions to stress, e.g. psychogenic symptoms and loss of function. Generally it measures conversion reactions, somatic symptoms, lack of insight into the causes of symptoms, denial, immaturity and self-centeredness and suggestibility. Hy has five Harris-Lingoes subscales to help discern what area of scale content was endorsed. Originally developed to identify homosexuality Mf now is thought to measure interests or stereotypical personality traits, not symptoms or problems (in fact it is not even considered to be a “clinical” scale although found within the clinical group). For men a low t-score means he has very traditional (“macho”) masculine interests. Without being too stereotypical, persons from Hispanic cultures frequently are thought to possess this personality trait.
A “code type” is a group of clinical scales that interact with each other. It is interpretable if the scores comprising the code type are ≥ 65; if they are ≥ 5 points higher than the remaining scales; and if they are within 5 points of each other. The code type for the person identified in the hypothetical is the two-point code type 13/31. It often is found in inpatient medical settings. It is associated with chronic medical or physical problems such as chronic pain and an Axis III diagnosis. Endorsers are preoccupied with physical health. Their symptoms appear and disappear quickly in response to emotional stress. They present themselves as psychologically normal and responsible. They typically resist psychological explanations for their difficulties, instead preferring medical answers. I would interpret this person’s scores on this basis.
11. Dr. Z. administers an MMPI-2 to a woman with ADHD who also has a history of impairment in verbal and written skills. While scoring the test he notices the woman did not answer 20 items and also had significant elevations on the Variable Response Inconsistency (VRIN) scale. How should Dr. Z. proceed?
ANSWER: Cautiously. As a matter of content-independent validity MMPI-2 permits a maximum of 30 CNS (“cannot say”) items. VRIN (“variable response inconsistency”) is designed to detect random responding. It comprises 47 item pairs, 12 of which can be scored two ways. T-scores range from 30 to 120. Generally speaking it is interpretable if the t-score is ≥ 80. VRIN also should be interpreted in light of its counterpart TRIN (“fixed response inconsistency”), which is designed to detect fixed or pattern responding. Based on the facts of the hypothetical, the test was not invalid based only on the number of CNS items. One would need to know what the actual VRIN score was in order to assess its contribution to validity. One also would need to know the TRIN score. All aspects of the MMPI-2 must be interpreted in light of the clinical interview preceding administration of the test. The hypothetical states respondent has ADHD and a history of impairment in verbal and written skills. She may not have been paying attention during the administration of the test, or her attention may have wandered. Although gauged at a 6th-grade reading level, she may have not understood some of the questions. While these facts tend to explain CNS/VRIN/TRIN elevations they also reduce my confidence the test is a valid determiner of the respondent’s personality states/traits.
12. Dr. Z. is asked to assess the IQ of a 10-year-old girl with academic difficulties. He administers only the non-verbal subtests of the WISC-IV (subtests from PRI and PSI) because he is concerned about the girl’s limited verbal skills. The girl obtains results in the low average range. Dr. Z. uses these results as an index of her overall IQ, and bases his recommendations on only these results. The child then is placed in remedial classes based on the test results and Dr. Z.’s recommendations. Dr. Z. defends his test administration and recommendations because of his concerns about the child’s limited proficiency in English. Was Dr. Z.’s test administration and interpretation ethical? Could he have taken any alternative steps in assessing this child?
ANSWER: No and yes. The WISC-IV generates a full-scale score (FSIQ) and four sub-scores: verbal comprehension (“VCI”), perceptual reasoning (“PRI”), processing speed (“PSI”) and working memory (“WMI”). It comprises ten core subtests, each of which is given equal weighting towards full-scale IQ. By dropping VCI and WMI Dr. Z. has eliminated important components of the respondent’s over-all IQ score and the result of the test therefore is uninterpretable. Research has shown WISC is not effective as a clinical tool. In particular it should not be used to diagnose ADHD or learning disabilities. Rather its best use simply is to evaluate a child’s intelligence and cognitive development in relationship to his or her age. Dr. Z. erred in using it as a device to place the child on a remedial class track. Dr. Z. also ignored the child’s limited English capacity. As an intelligence test WISC depends not only on language proficiency to understand it but also the role of language in formulating the constructs and phenotypes, which “intelligence” comprises. If Dr. Z. does not speak the child’s native language then she should find somebody who does. In summary Dr. Z. should have (a) administered the test in the child’s native language; (b) administered an alternative test; (c) interpreted the WISC-IV outcome in light of results on other tests and a clinical interview; and (d) in any event not used it as a criterion for education track placement.