Dual Relationships Sample Essay.
Example 1: A psychologist is seeing a client in therapy. The client tells him she can no longer pay for sessions. He has been struggling to deal with the paperwork imposed by managed care and billing. He suggests that the client can work for him 2 days per week instead of paying for sessions.
In the following pages, we will address how this example relates to ethical considerations for dual relationships. We will discuss what unethical and ethical actions could be taken when faced with a client who presents financial issues and offers to barter work to cover the cost of sessions. In addition, we will analyze the ethical issues caused by dual relationships. Psychologists are often faced with multiple ethical dilemmas. Many are boundary issues that arise when the patient/client becomes comfortable in the therapeutic relationship. We will discussthe challenges this creates throughout this paper.
Ethical decisions are expressive attempts to discover how moral decisions are made. Key terms that come into play when attempting to describe ethics include: ultraism, rationalism, and hedonism (ethics, 2003). One possible ethical alternative the psychologist may take in example one would be hiring a trustworthy part-time assistant to help manage the overload of paperwork imposed by managed care and billing. Otherethical solutions the psychologist may suggest could include guiding brainstorming with his client to help her come up with her own way(s) of earning extra money to help pay for sessions, explaining the importance of continued sessions to her mental health, and reiterating the ramifications of discontinuing any medications.
According to Kapp (2003), “Federal regulations promulgated in 2002 to implement the Health Insurance Portability and Accountability Act (HIPAA) impose on health care entities very specific requirements regarding the handling of personally identifiable medical information contained in patient records, and impose severe sanctions for unauthorized disclosures” (Kapp, 2003. para. 1). Hiring the patient part timeand continuing treatment after the patient/doctor line has been crossed could be considered unethical. Hiring a patient to take care of others’ confidential records is risky and may interfere with confidentiality agreements. Confidentiality is not limited to personal medical information about the patient.Billing information which includes payment issues or histories is also sensitive information that must be protected. Since the doctor in this scenario is assuming both caregiver and authoritative influence roles, a potential conflict of interest has been created. There is a strong probability that the patient mayno longer feel comfortable divulging confidential personal information to the doctor once the role change occurs.
The APA Ethics Code Standard 3.05 defines multiple relationships. A multiple relationship occurs when a psychologist assumes both a professional role and any non-therapeutic role with the same person. In our case example, the psychologist has assumed dual roles of therapist and employer. Other Ethics Code Standards such as standard 6.03: Fees and Financial Arrangements apply to our case example. If financial limitations to services can be anticipated, the therapist is obligated to address these issues with the recipient of services as early as is feasible. Standard 4.01: Maintaining Confidentially applies as well, as the patient would be dealing with other clients’ personal information.Standard 4.01 asserts that, in maintaining confidentially,“Psychologistshave a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.” (Fisher, 2013. p. 346) This brings us to Ethics Code standard 2.05: Delegation of work to others.This code states that “Psychologists who delegate work to employees, supervisees, or research or teaching assistants or who use the services of others, such as interpreters, take reasonable steps to (1) avoid delegating such work to persons who have multiple relationships with those served that would likely lead to exploitation or loss of objectivity.” (Fisher, 2013. p. 344)
Dual relationships can be professional, and unprofessional. An example of a professional dual relationship with a client could be acting as counselor, as well as teacher. An example of a non-professional dual relationship is a psychologist or therapist who is a close friend or who has intimate involvement with his or her client. Dual relationships must involve certain ethical considerations, and can often lead to legal issues if not handled professionally. Although dual relationships may seem more unethical than ethical, they can also set the bar for a stronger relationship, and a close bond between therapist and client. Dual relationships can benefit the client and his or her therapist if the relationships are handled ethically and with full consideration of all the potential ramifications of the additional relationship. The difference between ethical and unethical relationships involves the arrangement of mutual trust. Therapists often find itdifficult to avoid a dual relationship with clients, especially when it comes to co-workers and family. A therapist or psychologist’s job is to help people sort through issues they may be dealing with.It is very common for family and close friends to assume that such help is implied by the close relationship.
The dual relationship suggested in our case example could create a conflict of interest in many ways.The patient in our scenario will be the psychologist’s employee and patient. According to the ethics code 6.05: Barter with Clients/Patients,“Bartering is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services.” (Fisher, 2013. p. 348) The psychologist may barter “…only if (1) it is not clinically contraindicated and (2) the resulting arrangement is not exploitative.” (Fisher, 2013. p. 348)
Although the psychologist has offered what he feels is a good alternative for the patient to pay for her services, the dual relationship may create conflict between the psychologist, coworkers, and other patients in the facility who will consider taking advantage of this offer. If not offered a similar arrangement, other clients may feel discriminated against. The results could be detrimental to the continuation of services for those in similar situations.
Fisher (2013) also elucidates the potential for exploitation of the therapist in this scenario in referencing the need for any service or product received as payment for services to be measured against the actual cost of therapy sessions. Fisher (2013) is explicit in describing the risks involved with this type of multiple relationship. According to Fisher (2013), “Bartering clerical or other (e.g., house painting, babysitting) services for psychological services risks creating potentially harmful multiple relationships resulting from interactions with the client/patient outside a professional role or loss of professional objectivity in reaction to the quality of the client/patient bartered services.” (Fisher, 2013. p. 198)
As with any therapeutic relationship, the details of payment for services must be included in the original informed consent exchange. Because the potential for financial issues to arise after the therapeutic relationship has been formed, therapists must consider how best to address non-payment issues. An issue that may often be disregarded or evade consideration completely is the potential need for third party collection agencies to collect when patients/clients fail to pay for services rendered. To address potential legal issues arising from disclosure of private health information (PHI), “HIPAA permits covered entities to use and disclose PHI to carry out treatment, payment, or health care operations without specific authorization from the patient (45 CFR 164.506).” (Fisher, 2013. p. 197) According to this policy, third party collection agencies may be considered “business associates” who act on the behalf of, but not as employees of the covered entity who, for our purposes, is the therapist. (Fisher, 2013) When this unfortunate need arises, any interactions between the therapist and the collection agency must be made with intent to safeguard clients’ PHI in compliance with HIPAA. The HIPAA “minimum necessary” standard asserts that shared information must be limited to the patient’s name, the amount owed and/or overdue, dates of service, the client/patient’s address, phone number and other relevant contact information. “Psychologists should never reveal a client’s/patient’s diagnosis or reason for seeking services.” (Fisher, 2013. p. 197)
In summary, we see that an ethical decision for this scenario is to brainstorm with the client on ways to earn money to pay for sessions that are crucial to his/her mental health treatment. Hiring a patient to handle confidential patient files threatens confidentiality of patient records and is in violation of HIPAA requirements. It is also unethical because it can lead to the patient to regress and become wary of sharing information. This serves as an example of what a dual relationship would look like if the patient is hired by the psychologist. This particular dual relationship violates ethics codes 3.05; 4.01 and 6.03. Knowing the difference between ethical and unethical behavior in dual relationships, such as the example we have studied here,is critical in maintainingan arrangement of mutual trust.
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