Contextual Matters

In regards to contextual matters, client exceptions are ________ that permeate decisions about client care.

Additionally, ________ that emerge from diagnosis, managed care, and conflicts between institutional and professional values are considerations that require vigilance by value-sensitive therapists.

• meta-issues
• ethical issues

Ethical issues of context can often frame practitioner accountability in terms of compliance.

By contrast, ethical issues of ________ often introduce greater flexibility and choice for therapists. In many ways, such metters feature

• greater discretion for therapists' control 
• but greater individual accountability for resolution. 

Practice Matters

1. Multiple Relationships 
2. Technology
3. HIV/AIDS, Confidentiality, Client Welfare, & Public Protection
4. Research & Publication: Informing Ethical Practice

Relationships in which MFTs assume two or more roles simultaneously with a person or persons engaging their professional assistance.

These roles may be both professional in nature (e.g. therapist & supervisor) or a combination of professional and non-professional (e.g. therapist & friend/intimate).

MULTIPLE (DUAL) RELATIONSHIPS

1. so pervasive
2. difficult to recognize at times
3. sometimes unavoidable
4. sometimes harmful but may also be beneficial
5. the subject of conflicting advice
6. may compromise one's objectivity/impair one's professional judgment

• Compliance
• Resolution

1. Compatibility of Expectations
2. Divergence of Obligations
3. Power & Prestige Differential

Concern regarding multiple relationships that states that as the difference between the expectations of the therapist and client increases, the potential for misunderstanding and harm increases.

Stresses the importance of clear expectations regarding the therapeutic relationship.

The intimacy of the therapeutic relationship can readily lead clients to expect a "special type of friendship" and to invite therapists to participate in their lives outside of therapy. When allowed to continue, potential increases for multiple relationships that promote compromising/unethical behavior.

Compatibility of Expectations

Concern regarding multiple relationships that states that as the distinction between the responsibilities imposed by different roles increases, the potential for divided laoyalties and loss of objectivity increases.

ex) responsibilities assoc. with being ones therapist and ones neighbor

Divergence of Obligations

Concern regarding multiple relationships that states that as the difference in authority and influence increases between the roles of therapists and client, the potential likewise increases for

• exploitation on the part of the therapist 
• inability on the part of clients to remain objective about their own best interests

Power & Prestige Differential

1. Personal boundaries (e.g. avoiding intimate/friendship relationships)
2. Role of "political activist" or "religious activist"
3. Simultaneous/sequential function as therapist and evaluator
4. Multiple affiliations and allegiances to a variety of professional groups or agencies (e.g. member or AAMFT, NASW, licensed MFT)

Triangulation

MFTs have a special obligation to promote the welfare of the clients with whom they work. Consequently, even in relationships in which there is minimal danger of harm, they are ethically bound to exercise ________ by

• remaining sensitive to potential role conflicts 
• working to minimize their impact should they occur.

Due Care

Practice matter concerning the electronic connections and transmissions which have truly revolutionezed the sending and receiving of information.

Has important ethical implications for any type of therapeutic relationships as it can be used as a means of enhancing or exploiting therapeutic relationships.

TECHNOLOGY

1. Information Management System
2. Practice Resource
3. Therapeutic Modality

Use of technology for electronic storage of records containing identity information, standardized forms, diagnostic and treatment data, billing, progress notes, and archival records in a self-contained agency server.

An option for larger volumes of client records is an off-site database designed with specialized encryption procedures to limit access to only authorized persons.

Information Management System

Practice Resource

Use of technology for online MH services, often described as web therapy, cybercounseling, e-therapy, and a host of other terms which have emerged in recent years.

These practices concern using technology-based interventions as the primary application of therapy services.

Therapy Modality

1. Online Care
2. Electronic/Text Messages & Social Networks

***Competence in online therapy requires attention to the technological aspects of the medium of technology. Due care in both the content and the format of cybertherapy is a reasonalbe expectation of clients who must place their trust in the practitioner and the medium.

Thus, clients should be assured of the therapists: (2)

• Technical Ability
• Therapeutic Skills

***The issues of informed consent are equivalent in face-to-face therapy and online therapy. However, the procedures for addressing these issues may differ appreciably.

For purposes of informed consent about ________, therapist may encourage online clients to verify their credentials with licensure boards, certification bodies, or similar professional agencies.

Practice Competencies

Ethical practice matters of online intervention in which the potential for these forms of technology to affect face-to-face therapy is possible/likely, and  can affect conventional client care.

Allowing or even encouraging clients to expect greater access, faster responses to nonemergency contacts, and opportunities for casual exchanges can threaten one's expert power in the ecology of therapy.

Electronic/Text Messages & Social Networks

HIV/AIDS, CONFIDENTIALITY, CLIENT WELFARE,

&

PUBLIC PROTECTION

1. Accepting & Adjusting to Diagnosis (info & educ)
2. Evaluating Personal Disclosure Skills (emphasis on pros, cons, difficulties, strategies)
3. Taking Inventory of Who Should be Told (highlighting issue of family boundaries)
4. Evaluating Potential Recipients' Circumstances, such as health/age (addressing feelings of guilt, anxiety, sadness for telling some members but not all, and developing plans for disclosure)
5. Anticipating Reactions of Recipients, such as anger/support (clarification of possible reactions)
6. Motivation for Disclosure, such as desire for support/obligation (defining personal needs and identifying family members likely to meet needs)

...the duty to protect third parties from violent behavior by a client believed to be dangerous.

The question of what to do in circumstances such as the ethical dilemma of  obligation to clients vs third parties relative to AIDS is answered in the Tarasoff decision which states that confidentiality within psychotherapy is to be highly values, but never regarded as absolute.

Therapists' obligations to the patient require that he/she: (2)

• not disclose a confidence unless necessary to avert danger to others

• do so discreetly and in a fashion that preserves the privacy of the patient to the fullest extent compatible with the prevention of a threatened danger

1. respecting autonomy
2. maintaining integrity
3. benefiting clients
4. fostering responsibility

1. Fiduciary Relationship
2. Identifiability of a Victim
3. Forseeability of Danger

Fiduciary Relationship

Regarding HIV-positive clients, states that the duty to protect extends only to recognizable victims and not to all persons whom a client could potentially harm, such as sexual or needle-sharing partners.

Does NOT necessarily extend to casual sexual or drug partners unless they were readily identified.

Identifiablity

Foreseeability

Behaviors that do not appear to give rise to a duty to protect, as evidence suggests that HIV infection cannot occur through food, tears, urine, or insect bites. 

ex) casual non-sexual contact, living together

Low-Risk

Behaviors that clearly give rise to a duty to protect, the presence of which should be assessed in the context of establishing and enhancing a therapeutic relationship because the primary goal of psychotherapeutic efforts is to empower clients to be responsible for own well-being and that of another.

ex) unprotected sexual contacts and sharing of needles which are the primary modes of HIV transmission

High-Risk

Behaviors for which the duty to protect may be present, but the foreseeability of danger to others is less apparent.

ex) "safe sex" w/out informing partners of their infection

Intermediate-Risk

In a report regarding the decision-making considerations of MFTs when faced with ethical quandaries of unauthorized disclosures of (a) resporting suspected child abuse and (b) preventing HIV transmission, this qualitative approach distinguish between

________, such as personal/therapeutic response, professional ethics, and legal considerations/laws of state, and

________, such as the principles of beneficience, nanmaleficience, autonomy, justice, and fidelity.

• Lower-Level Components
• Higher-Level Components

In a report regarding the decision-making considerations of MFTs when faced with ethical quandaries of unauthorized disclosures of (a) resporting suspected child abuse and (b) preventing HIV transmission, the author reported that 

lower-level components most common in decisions related to

suspected child abuse included: (2)

HIV transmission: (1)

while the higher-level component most common in both was: (1)

Professional Ethics

Legal Considerations

Professional Ethics

Nonmaleficience

Depending on the level of risk for transmission, clients' voluntary disclosure of their HIV status should be a more or less immediate focus in therapy.

In making a final determination, factors that must be taken into account include: (3)

1. Client's Credibility
2. Perceived Degree of Concern for Identifiable Victim
3. Overall Sense of Social Responsiblity