When is a patient’s behavior unacceptable?
January 1, 2007
During my internship, a client offered to barter with me an expensive, stolen camera for 80 therapy sessions. To my embarrassment, my response of “Would you like to tell me some more?” and the discussion was recorded and heard by my supervisor and my supervision group.
Further exploration of my “clinically neutral” response brought up the question of why my extensive background in critical thinking did not come into play. Even though I grew up with high moral values and I left my homeland for moral reasons, none of that seemed to manifest in the therapy session.
The question then becomes, what is unacceptable and how to respond to actions that are deemed unacceptable by therapists? While important, the question of what is unacceptable is mostly discussed in limited terms of our expectations of our clients to pay us and show up on time during training and supervision. This short article proposes ways to organize how we ought to think about what is unacceptable in regard to our clients’ behavior.
The dictionary informs us that unacceptable means not allowable, intolerable, insufferable, inadmissible, inappropriate, undesirable, unreasonable, offensive, obnoxious, disagreeable, disgraceful or deplorable. The importance of defining what is unacceptable for therapists lies in the fact that we often model to clients healthy, adaptable or appropriate social exchange and have a unique opportunity to give them feedback they may not get anywhere else. Much of our clients’ suffering and alienation is a result of their “unacceptable” behavior. One may argue that we do them a disservice if we don’t provide appropriate and potentially helpful, honest and authentic feedback.
There are many ways that therapists perceive their clients’ behavior as unacceptable. What is acceptable to one therapist in a certain situation with a certain client may not be acceptable to another in a different situation with a different client. This article aims to help identify and calibrate their professional, moral and ethical compass when it comes to unacceptable behavior rather than discuss when, how or whether to convey what is unacceptable.
What makes a situation acceptable or not depends on five types of factors:
- Client factors: These include client’s culture, age, gender, mental disorder, sexual orientation, personality etc. For example, it may be perfectly acceptable if a child-client jumps onto the therapist’s lap in the middle of a family therapy session. However, the same behavior from an adult would be viewed as highly unacceptable under almost any circumstance.
- Setting factors: These include outpatient vs. inpatient; solo practice vs. hospital based clinic; large, metropolitan area vs. small, rural town. For example, it may be unavoidable, and therefore acceptable, for a therapist to be naked with a client in the locker room of a small town’s only gym. However, being naked with a client in any other circumstance is highly likely to be unacceptable.
- Therapeutic factors, such as modality: individual vs. family vs. group therapy; psychoanalysis vs. humanistic vs. body psychotherapy. For example, it may be acceptable for a client to leave his/her chair and walk around the room in the behavioral therapy of a client who is learning to cope with anxiety. However, leaping off the analytic couch is probably not acceptable in traditional psychoanalysis.
- Therapeutic relationship factors: quality and nature of therapeutic alliance, i.e., secure, trusting or fearful connection; beginning vs. end of therapy; presence or absence of dual relationships. For example, a client giving a gift to the therapist in the first session is likely to be unacceptable in comparison with a gift given in the last session before termination.
- Therapist factors: culture, age, gender, sexual orientation; scope of practice (i.e., training and experience). For example, a therapist of a certain culture may find certain expressions or actions by the client of the same culture more acceptable than a therapist from a different culture.
Unacceptability may fall into several categories described below:
- Legal or duty: These are the situations where the client presents danger to self or others and there is a duty to warn.
- Clinical responsibility: Family and group therapy may present a situation where the therapist has the responsibility to avert dangerous, threatening or destructive behavior to other clients or behaviors such as reckless sex or reckless driving.
- Professional reasoning: It is often unacceptable for therapists when a client deliberately does not pay therapy bills, comes to session intoxicated, is chronically late or aggressively seductive.
- Putting therapists at risk: Therapists may find it unacceptable if a client consistently puts the therapist at risk by hinting about harming themselves or others, vaguely discussing child pornography or confessing to past or future crimes.
- Language: Depending on the setting, certain sexist or racist language can be unacceptable.
- Violation of therapist’s space: Most therapists encounter clients who ask them intrusive questions. What is intrusive is highly determined by the therapist’s attitude and comfort with self-disclosure. Almost all therapists find that clients stalking or threatening them or their family members is unacceptable. These include clients causing actual damage to the therapist’s office, showing up at the office unannounced or inappropriately searching for information about the therapist online.
- Violating therapist’s moral or ethical sensibility: This is a very broad category and is as diverse as therapists’ moral compasses, spiritual orientations and ethical stances. Some therapists may find cruelty to animals, reckless pollution of the environment, unprotected reckless sex, violent pornography and many other client behaviors as repugnant, immoral, unethical and therefore unacceptable. Criminal activities, extortion or theft may also be unacceptable. This category is highly personal. What may be unacceptable to one therapist may be lauded by another, as the examples of a tax or draft resister.
It is hoped that reading this article will help therapists articulate what is unacceptable and on what grounds it is unacceptable. Differentiating between personal morality, professional ethics and legal mandates is important. My sense is that if I had read this article prior to being offered the stolen camera, I would have gifted my client with the authentic and appropriate response rather than an amoral or even immoral clinical neutrality.
Ofer Zur, Ph.D., is a forensic expert on ethics with emphasis on boundaries. He offers online continuing education and numerous free articles at www.drzur.com. He authored The Private Practice Handbook, HIPAA Compliance Kit and co-authored Dual Relationships and Psychotherapy. His latest book is Boundries in Psychotherapy published by APA Books.
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