We have been told, “Don’t touch your clients!” “Minimize self-disclosure!” “Never venture outside the office with a client!” “Avoid bartering!” And, of course, “Avoid dual relationships at all costs!”
These “don’ts” and many others whisper to us as we emerge from most risk-management workshops and ethics-and-law seminars or while reading an attorney’s or (so-called) experts’ columns or blogs.
Under the guise of risk management and self-protection, we are told, Beware! The slightest deviation from these ersatz commandments will set us on the “slippery slope” to perdition.
Risk management, the way it is often taught, means to avoid actions that may not look good in court or in licensing board hearings, regardless of their therapeutic value.
But it is possible for us to protect ourselves while preserving clinical, ethical and moral integrity. I believe we can touch clients appropriately, self-disclose when helpful, barter when necessary and appropriate, exchange gifts if it is therapeutic and engage in non-exploitative dual relationships without increasing the risk of being sued or losing our licenses.
Full guidelines are available at: zurinstitute.com/riskmanagement.html#guidelines
Do what it takes to help clients while ensuring that you do no harm. Show respect for them and never humiliate or exploit them or assail their dignity. Place their welfare above your fear of boards, courts, ethics committees and attorneys.
Remember you are not paid to practice defensive medicine or risk management. Your duty is to help clients with the concerns and problems they are paying you to remedy. Intervene with them according to their problems, concerns, needs, gender, personality, situation, venue, environment and culture.
Provide a safe and trusting place for healing and growth. Protect and respect client privacy and confidentiality, unless it fails to safeguard the client, community, etc., from harm or as required by the law. Intervene in the most clinically effective way, not according to dogma. Different problems often require different clinical interventions.
Do your best to avoid situations with conflicts of interest (regretfully, this is not always possible) and be aware of the standard of care in your community, often referred to as the usual and customary professional standard of practice.
Keep good records. They are extremely important from clinical, ethical, legal and risk-management points of view.
Make sure they include informed consents and office policies, initial and updated treatment plans; records of consultations, tests, etc.; releases or authorizations to release information; important communications to and from clients; an initial assessment and MSE; referrals for medication evaluations, testing and other professionals or programs; and details about termination.
Consult with experts and educated colleagues in complex and unusual cases. Document the consultation in your clinical notes.
Several types of cases or situations merit special attention and a greater degree of caution. They include child custody, repressed or recovered memories, domestic violence and child abuse.
Types of clients and Dx who merit special attention include those with borderline personality, multiple personality or other dissociative disorders; those who are antisocial, paranoid, suicidal or homicidal, and those with a history of litigation.
Never have sexual contact or sexual relationships with current clients. Seek ethical, clinical and legal advice before entering into sexual relationships with former clients.
Handle client debt with sensitivity. Be cautious before resorting to debt collection agencies, which may trigger client complaints to licensing boards.
Practice within the limits of your expertise and scope of practice as determined by your education, supervised training and clinical experience.
Terminate thoughtfully and appropriately. (zurinstitute.com/termination4_course.html). Do not abandon clients. Offer referrals and follow-ups when appropriate. Document clearly who initiated the termination, when, the nature of the discussion and potential referrals. Summarize their treatment in records: what was and was not achieved and to what extent.
If the client terminates abruptly against your clinical judgment, send a polite letter expressing your concerns in a clinically appropriate and sensitive way. Offer to continue therapy or to refer the client to another therapist. Note that you are willing to help with the transition.
Be thoughtful about crossing boundaries, including out-of-office experiences, gifts, bartering, touch and self-disclosure. Document these interventions and, when appropriate, include them in treatment plans and ground them in a theoretical orientation.
Be thoughtful about dual relationships. (zurinstitute.com/drcourse.html). While many forms of dual relationships are unavoidable, ethical and potentially helpful, therapy never involves sexual or exploitative business relationships. Include a statement on dual relationships in the office policies and the informed consent. Document all dual relationships, avoid those that may result in a decrease in objectivity or clinical judgment and consult on complex cases.
Pay attention to vicarious liability, such as renters or co-workers.
Finally, prevent your own burnout. Create balance in your life between professional work, familial, recreational, communal, political and/or spiritual activities.
Ofer Zur, Ph.D., is director of the Zur Institute, an Online Continuing Education Program. He is a licensed psychologist, instructor, forensic and ethics consultant and expert witness in private psychotherapy practice in Sebastopol, Calif. His latest book (2017) is Multiple Relationships in Psychotherapy and Counseling: Unavoidable, Common and Mandatory Dual Relations in Therapy published by Routledge. His website is: https:///www.zurinstitute.com/contact-dr-ofer-zur/