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INFORMED CONSENT

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The overarching ethical principle of showing respect for patients’ autonomous ability to make their own decisions is reflected in the American Psychological Association (APA, 2010) Ethics Code through standards that require psychologists to provide information to, and secure consent from, consumers of psychological services (e.g., Standard 3.10). The doctrine of informed consent stems most directly from General Principle E: Respect for People’s Rights and Dignity, which urges psychologists to respect the self- determination of others.

Respect for patient decision making has influenced the wording and content of other standards in the APA Ethics Code. For example, advertising should be guided by transparency and accuracy so that prospective patients can make informed choices as to whether to seek services from a particular psychologist. In addition, respect for patient autonomy guides the selection of treatment goals. In this chapter, we review difficult ethical problems for which

http://dx.doi.org/10.1037/14670-008 Ethical Dilemmas in Psychotherapy: Positive Approaches to Decision Making, by S. J. Knapp, M. C. Gottlieb, and M. M. Handelsman Copyright © 2015 by the American Psychological Association. All rights reserved.

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respect for patient autonomy is especially important. Other issues dealing with respect for patient autonomy are considered in Chapter 9.

WHAT TO PUT IN ADVERTISEMENTS

In Standard 5.01b, the APA Ethics Code identifies certain activities that are unethical in advertising:

Psychologists do not make false, deceptive, or fraudulent statements con- cerning (1) their training, experience, or competence; (2) their academic degrees; (3) their credentials; (4) their institutional or association affilia- tions; (5) their services; (6) the scientific or clinical basis for, or results or degree of success of their services; (7) their fees; or (8) their publications or research findings.

Other than additional restrictions on testimonials (Standard 5.05), the APA Ethics Code says little else about advertising. From the standpoint of positive ethics, psychologists want to do more than just refrain from violating 5.01, 5.05, and other relevant standards. Instead, they want their advertisements to help patients make informed decisions about services. Nonetheless, and especially given the ubiquity and “freedom” of the Internet, separation strate- gies may include the idea that advertising is an ethics-free zone if additional prohibitions are not mentioned in the APA Ethics Code. At that point, eco- nomic self-interest, business frames for advertising, or other factors unrelated to psychology ethics determine their course of action.

Positive ethics, of course, provides additional guidance in the form of over- arching ethical principles, virtues, and values. For example, would it be ethical for a psychologist to advertise himself as “The Sportsman’s Psychologist,” with a picture of himself holding a gun and wearing a hunting outfit? Would it be ethi- cal for a psychologist to indicate on her website that her hobbies are hiking and playing tennis? Some questions to ask include, Are these advertisements consis- tent with professional values, such as respecting patients’ autonomous decision making by giving patients accurate and useful information to help them decide whether to seek services from a particular psychologist? Are the messages mis- leading in some way? Looking at advertising from the perspective of trying to help prospective patients, it may be appropriate for a psychologist with expertise in sports psychology to note, for example, that she was a collegiate tennis cham- pion; such information may be relevant to the decisions of prospective patients. It may be appropriate for a psychologist with an interest in treating religious patients to note that he or she is an ordained member of the clergy.

Reasonable psychologists may disagree on whether certain disclosures can be linked to overarching ethical principles. One psychologist noted that

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he had lived in the city all his life. Although some readers may view this as an unnecessary self-disclosure, he considered it an indication that he was aware of the community’s values and local resources. He also judged that the information was unlikely to cause harm (nonmaleficence).

Other forms of self-disclosure in advertising appear more problematic. One psychologist worked part time as a singer and, on her professional website, included a link to samples of her recordings. This practice raises the issue of whether psychologists should place unrelated secondary occupations on their professional website. Although it may not be an explicit violation of the APA Ethics Code to include such information, doing so enhances the opportunity for potentially contraindicated boundary crossings and multiple relationships. A preferred integration strategy would be “boundary bolstering” (Anderson & Handelsman, 2010, p. 83), such as the one adopted by a colleague of ours who buys and sells classic guitars. He maintains two separate websites: one for his practice and one for his business. Neither site gives any hint of the other.

Psychologists using separation strategies may disclose information as they would to friends or social acquaintances in which mutual self-disclosure is a norm. But some behaviors that are acceptable or even desirable in social relationships may be contraindicated in professional ones in which self- disclosure needs to be selective and focused on patients’ needs. A psycholo- gist whose professional website contains a link to her singing web page also may be using a marginalization strategy to the extent that she would be happy with the sale of a couple tunes, even if it ran the risk of decreasing the effec- tiveness of her clinical services.

Ethical fading (Bazerman & Tenbrunsel, 2011), that is, when the ethical dimensions of a situation become overshadowed by practical, monetary, or other nonethical concerns, can occur in decisions about advertising. If psy- chologists think about advertising only in terms of how to maximize referrals (a business frame), then the ethical implications of advertising (an ethical frame) may fade away in the decision-making process. Psychologists can reduce the risk of ethical fading by keeping ethical principles in mind from the beginning of their deliberations.

RESPECTING PATIENT DECISIONS CONCERNING TREATMENT GOALS

Beginning at the outset of treatment, psychologists need to have informed consent discussions to ensure that patients understand a variety of relevant information, including “the nature and course of therapy, fees, involvement of third parties, and limits of confidentiality” (Standard 10.01, Informed Consent to Therapy). Psychologists who value respect for patient

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autonomy and practice positive ethics will want to involve patients—at the start of the relationship and at points throughout the course of treatment—in as many treatment decisions as is clinically indicated.

Agreeing on Treatment Goals With Children and Adolescents

Standard 3.10b of the APA Ethics Code requires psychologists to “seek the . . . assent” of those who cannot legally consent to treatment. In Chapter 2, we discussed the need to balance respect for the autonomy of the child or adolescent receiving treatment as a matter of beneficence (the welfare of the child) with respect for the autonomy of the parents who must authorize treat- ment. Often, disagreement about goals can involve highly sensitive informa- tion. This example expands on that theme:

Sexual Orientation Issues With an Adolescent An adolescent presented for treatment with symptoms of depression.

The psychologist decided to see the boy in individual therapy, and over time it became clear that he was struggling with feelings of attraction to individuals of the same sex. The parents, who were conservative Chris- tians, would likely view same-sex attraction as a moral failing and would expect the psychologist to work to rid their son of these feelings. The psychologist was gay affirmative and would not agree to do so.

Should the psychologist continue to see the boy and accept payment from the parents, even though she is working on issues different from what the parents expected and is accepting behaviors or feelings that the parents would likely find offensive? Beneficence would suggest that the psychologist should con- tinue to treat the boy with a therapeutic stance that allows him to express his sexual feelings freely. Also, respect for patient autonomy would suggest that the adolescent has the right to choose the topics he wishes to explore. However, consider the potential for conflict of interest: Seeing the adolescent would be in the psychologist’s self-interest in that the patient would continue in treatment, and seeing him would mean additional income. Because the psychologist is gay affirmative, seeing the boy will advance the public accep- tance of the therapist’s views and agenda on sexual orientation. On the other hand, meeting the boy’s needs most likely conflicts with the parents’ goals and interests; if so, they may refuse to pay for further therapy and may terminate treatment, even though it may not be in their son’s best interest.

In this case, many psychologists would agree that the importance of having the adolescent explore his sexual feelings trumps respect for the par- ents’ rights (beneficence trumps respect for autonomy). This alternative could be viable if the psychologist’s informed consent process included the provision that he could give the parents accurate but incomplete information

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concerning the nature of their son’s treatment. For example, the adolescent and the psychologist could agree on what to tell the parents about the nature of therapy and the manner in which the parents are told (e.g., a phone call between the psychologist and parents or a face-to-face meeting that included the psychologist, boy, and parents). The psychologist could, for example, accurately describe general symptoms, such as anxiety and depression, as reasons for continued sessions. Out of concern for the anticipated effect on the parents and the boy, the psychologist could discuss with him whether to reveal that there are other sensitive topics that he chooses not to share. If specifically asked what they are, the psychologist, based on his consultation with the teen, can decide whether to reveal more information, and if so, how much.

The psychologist also could consider how the parents may have inter- preted the informed consent information. For example, even though the psychologist informed the parents that he would not share certain sensitive information, neither he nor the parents could have anticipated that this issue would arise and that the parents may consider this much more than just another “sensitive topic.” If so, and the parents learned of their son’s sexual concerns and that they had not been informed of them, they may react with feelings of betrayal, regardless of how thorough the informed consent process may have been.

The psychologist would do well to consider how his emotions and other nonrational factors may influence his deliberations. He may ask himself, Am I stereotyping the parents and their religious beliefs? If so, is there a risk of confirmation bias on my part? Am I placing too much importance on my patient’s sexuality—relative to other issues—because of my own political beliefs and personal experiences with discrimination? How might my own experience with issues of sexual preference, and my experience with religious patients, be short-circuiting my assessment of the relevant ethical principles and alternatives? Do I fear loss or embarrassment, and are these feelings lead- ing me to misjudge the risk associated with the alternatives I am consider- ing? What System 2 questions might I be missing by focusing on System 1 concerns?

We know one psychologist with a long background of promoting fair- ness for sexual minorities who consciously monitors his thoughts on the value of coming out when he deals with patients who are questioning their sexual orientation. Although he sees the social value that occurs when gay men pub- licly discuss their sexual orientation, he is aware that his primary obligation as a psychologist is to help patients make their own decisions. The failure to take such a position could be considered intrusive advocacy (Pope & Brown, 1996), wherein the political agenda of the psychologist trumps the patient’s autonomous decision making.

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Agreeing on Treatment Goals With Adult Patients

Most of the time, psychologists can agree on treatment goals with their adult patients. However, respect for patient autonomy may conflict with other values. Consider the following example involving a seriously depressed patient:

The Unwilling Prostitute A psychologist worked with a 21-year-old college student who was

involuntarily involved in prostitution; she initially got involved volun- tarily, but soon found herself trapped in a coercive relationship. Her par- ents knew that their daughter was upset, and they paid for therapy, but they did not know the reason for her distress. The patient believed that she would be beaten or maimed by her pimp if she were to stop, and she appeared highly traumatized.

The psychologist wanted to uphold beneficence by alleviating the symptoms of depression and helping the patient extricate herself from her situation. However, the patient saw herself as hopelessly trapped, and if the psychologist fully respected patient autonomy, she would not have challenged the patient’s acquiescence to her circumstances. However, the psychologist judged that the situation was not in the patient’s best interest and that she could not make an informed or autonomous decision while in such a compromised state. Consequently, she proceeded with treatment of depression and trauma, but also gently insisted that a social worker with experience in helping women involved in prostitution join them for a session of therapy to discuss ways in which the patient could extricate herself from “the life.”

Because of the potential for harm to the patient, the psychologist acted paternalistically; that is, she trumped what the patient believed to be in her best interest, even though it meant raising an option that the patient did not want to consider at the time. Although, in general, the psychologist respected her patient’s autonomy, she concluded that in this situation beneficence dic- tated trumping autonomy to protect her patient from a situation in which she seemed unable to act on her own behalf. Some may consider this weak or soft paternalism (Feinberg, 1986) because the patient’s ability to make decisions about the focus of treatment was partially compromised, and thus the infringe- ment on autonomy was minimal, and the intervention served to increase the patient’s ability to make independent decisions.

On the other hand, the psychologist could have done nothing to address the issue of prostitution and not invited the social worker to become involved. That option may represent an assimilation strategy, albeit an overly simplistic one: “I’m here to serve the goals of the patient. She’s legally competent, so I’ll

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do as she asks.” Another factor driving this alternative may have been igno- rance or unrealistic fear on the psychologist’s part. What the therapist knew about prostitution came from TV programs that portrayed violence. Because of the availability heuristic, the psychologist may have based her decision on the information that was available to her and overestimated her own vul- nerability to violence as a matter of self-interest, and she avoided the issue altogether.

At the other end of the continuum, the therapist could have insisted that the social worker get involved and that the patient remove herself immediately from prostitution before initiating therapy, presuming that no treatment would be effective under the circumstances. This alternative could represent a separation strategy in which the therapist overrode her profes- sional respect for autonomy and concern for the patient with her personal agenda in a way that was incompatible with her therapeutic role.

Consider a similar situation:

A Victim of Blackmail A young woman had been abused by a neighbor as a teenager. Later,

this man blackmailed her into having sex with him, threatening to tell her husband about this history if she did not accede to his demands. She agreed, believing she had no choice, and quickly became seriously depressed. She felt ashamed and debased by her actions; she greatly feared that her husband would leave her if he found out.

Although the patient was seriously depressed, she was able to participate meaningfully in treatment once she had been stabilized on medication. The psycho logist was supportive and nurturing, but she refused to accept the patient’s premise that the blackmail was inevitable and that her patient had no alterna- tives. The therapist pursued the goal of changing the patient’s blackmail situ- ation, judging that respect for patient autonomy did not mean failing to offer alternative ways of viewing the situation.

This situation is another example of ethical gradualism (Francis, 2009; see also Chapter 2, this volume). The psychologist knew that goals can change over the course of psychotherapy and that goal setting often is an evolutionary process. Thus, the psychologist could agree to work on the patient’s depression in the short term and defer work on the blackmail. She had strong personal values about honesty and knew in her heart that psychotherapy would (or at least should) take a course that included alternatives to the blackmail. She also knew that not telling the patient about her (the therapist’s) long-term goals did not feel good to her. However, she recognized that complete hon- esty at such an early stage in treatment would be a separation strategy. When she considered her value of honesty in light of the value of compassion, the

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virtue of benevolence, and the relative weights of beneficence and respect for autonomy, she was able to adopt the integration strategy of working honestly on the goal of lifting the depression and deferring a more detailed and difficult discussion of long-term goals.

Adopting such a strategy was not easy for the psychologist. As a femi- nist, she was personally outraged by her patient’s situation and was tempted to pursue intrusive advocacy. As she thought about it, she realized that, had she done so, she would have been acting more from her own goals than those of her patient. Fortunately, the psychologist was able to take her emotional tem- perature (i.e., monitor her emotional reaction to the situation; Gino, 2013), step back, and reflect on the clinical facts of the case, and then proceed in accordance with a reasonable treatment plan.

Here is another example:

A Polyamorous Life During the course of therapy, a patient reported that he and his wife

had an open marriage and freely engaged in sexual relationships with a range of partners. As treatment proceeded, the patient wanted to spend much of the time trying to convince the psychologist of the acceptability of his polyamorous lifestyle. The psychologist continually had to redirect the therapy into more clinically relevant issues, but soon the patient informed the psychologist that he was trying to convince his 18-year-old daughter of the values of such a lifestyle.

The psychologist felt a conflict among ethical principles. He respected the patient’s lifestyle as long as it did not involve harm to others. However, he knew that teenagers are at increased risk of exploitation and harm, and this situation could be especially problematic, because it was her father who was suggesting she do this. Consequently, the psychologist believed that general beneficence (protection of the daughter’s welfare) required him to address this issue with the patient, and he assertively discussed with him the importance of allowing the daughter to make her own decisions. Presenting alterna- tives to the patient does not necessarily mean trumping his autonomy; how- ever, given the age of the girl and her risk for exploitation, the psychologist believed that trumping the patient’s autonomy was justified.

What factors might have led the psychologist to a different course? If the patient’s daughter were 25, then he might assume that she was less vul- nerable to exploitation, and his concern for her would be reduced. If the psychologist had strong religious beliefs opposed to the patient’s views or strong political beliefs in agreement with the patient’s, then he would need to monitor his behavior so that he did not appear to be engaging in intrusive advocacy or, on the other hand, allowing his similar beliefs to blind him to potentially problematic behaviors.

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PURSUING INFORMED CONSENT IN UNUSUAL CIRCUMSTANCES

Sometimes patients are in situations in which they do not anticipate what questions to ask, and they may be vulnerable to making ill-advised or ill-considered decisions. Consider this example:

Appearing on a Talk Show A psychologist was called by a producer of a TV talk show to see if she

would be willing to treat a patient with obsessive–compulsive dis order (OCD). The treatment would be paid for by the TV show, with the understanding that the patient and psychologist would agree to appear to talk on camera about the treatment.

What factors should the psychologist consider in evaluating this request? One factor is the nature of the TV show. The show may exploit people with mental illness by focusing on bizarre or unusual symptoms in a sensational- istic fashion. On the other hand, if the program took a more even-handed approach, their appearance could educate the public about OCD and avail- able treatments, thereby contributing to general beneficence. Fortunately, this particular talk show had a reputation of presenting mental health informa- tion in a helpful and respectful manner.

A second factor, given the unusual circumstances, is the likely effect of the therapy on the patient. Some talk show interventions have been poorly planned. One talk show offered enough money for 10 sessions of therapy, but, given the severity of her problems, the patient needed long-term treatment, medication, and probably a social worker to help her handle multiple agency problems. In that case, the show’s offer was clearly inadequate.

Talk show hosts have had guests with dramatic life situations, such as a patient with serious hoarding problems. In such situations, it is reasonable to ask whether the attention given to the patient’s problem could be harmful. Will being on the show consolidate the patient’s identity as a sick person?

The requirement for the patient to appear on the program again to talk about the treatment raises other important questions. Will the patient appre- ciate the loss of privacy involved in appearing? Would reappearing on the show create additional pressure that could disrupt the therapeutic progress the patient may have made otherwise?

A third factor to consider is the competence of the therapist, both to perform the therapy and to perform on TV. In one situation we know of, a psychologist who was asked to treat a “television patient” was skilled in the treatment of OCD, had presented at national conferences, and had partici- pated in national organizations that included professionals and consumers. He also believed strongly in the importance of educating the public about the

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disorder and had experience doing so via lectures and the media. He also did not agree to appear on the show until he had personally evaluated the patient to determine if he could be of assistance, and if the patient was fully informed.

Other psychologists may have more difficulty making a judgment about their competence. For some, the self-interest involved in appearing on TV, whether motivated primarily by money, the chance to educate the public, or other self-serving factors, may alter choice making by influencing psycholo- gists to discount arguments against competence. Alternatively, fear of appear- ing on TV may lead them to discount their competence and relinquish an opportunity.

TV has its own cultural values and traditions. Thus, the ethical accul- turation task for psychologists may be more complex. For example, consider informed consent. In the therapy room, psychologists can take steps to assess how free patients feel to refuse services, and either therapist or patient can take steps to refer, end therapy, or change the nature of the interaction. Such options may not be available in the studio, which may be sufficiently coercive (for both therapist and patient) that the process of informed consent does not get the attention it deserves. A separation strategy may involve insisting that the informed consent process be identical to the one the psychologist uses in the office. Such a strategy may entail blindly assuming that if the patient agreed, he must know what he is getting into—after all, people getting therapy appear on TV all the time.

The informed consent process is also important in dealing with confi- dentiality. Clearly, confidentiality issues are different when therapy occurs in front of cameras and an audience. Therefore, the ethical obligation (APA, 2010; Standard 4.02) to discuss confidentiality arrangements early in the relationship becomes especially important.

To deal with these factors, the psychologist in the preceding case used quality enhancement strategies. He reflected on his motivations—both noble and base—for an appearance. Although he wanted to educate the public regarding OCD, he realized that appearing on national TV was self-serving in that it would be a marketing opportunity that could enhance his national stature. After the intake interview that confirmed the OCD diagnosis and advisability of treatment, he consulted with a trusted colleague. As part of the consultation, the psychologist asked his consultant to review the intake to determine whether he was missing any significant factors. After the consul- tation, he spoke with the patient and focused heavily on empowering her to make her own decisions.

In the course of this discussion, the psychologist reviewed, in some detail, the limits to confidentiality as they applied to the patient. He candidly reviewed the manner in which a TV appearance might influence the patient’s motivation and the resulting risks to treatment effectiveness. He reviewed the

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general nature of the treatment with the producer to make advance arrange- ments about the conditions of his acceptance. He also sought to clarify the financial arrangements. For example, would the show pay for additional treat- ment costs and referral to a psychiatrist for medication, if necessary? If so, how much would they pay and for what period of time? The psychologist was able to integrate the important values of his profession with the traditions of the TV industry and his own personal morality.

One may think that this advance planning was strictly a matter of risk management for the psychologist; he pursued these issues in such detail, though, because he knew that the patient might not be aware of the potential pitfalls. As a result, his additional efforts also were a matter of beneficence.

SHOULD PSYCHOLOGISTS CONDUCT INTERNET SEARCHES ON THEIR PATIENTS?

Sometimes patients will ask a treating psychologist to look at their Facebook page or other Internet sources to help the psychologist better under- stand their life circumstances. A review by Kolmes and Taube (2014) reported wide ranges (between 18% and 95%) in the results of studies that looked at the percentage of psychotherapists who reported conducting Internet surveys on their patients. However, should psychologists conduct Internet searches routinely on patients without their knowledge or consent? (For further read- ing, see Kaslow, Patterson, & Gottlieb, 2011.) It is no more illegal to conduct an Internet search on a patient than it is to watch them walk down the street; after all, information on the Internet is public. But the fact that doing so is not illegal does not mean that it is ethically or clinically indicated. The overarch- ing principle of respect for patient privacy would suggest that psychologists not seek any additional information without the patient’s consent, except under highly unusual circumstances. Information gained from the Internet has never been necessary to conduct treatment before, and no research has suggested that using it now will enhance treatment effectiveness. Thus, it becomes hard to argue that Googling patients without their consent would promote their well-being. Furthermore, there is no guarantee that the infor- mation found on the Internet will be accurate, representative, or current. Therefore, proceeding based on such information risks unnecessary harm.

If psychologists use information obtained from the Internet as a basis of their treatment plans or case conceptualization, a question arises as to the extent to which patients were informed and involved in determining the nature of their treatment goals. In addition, a psychologist whose treatment plan depends on information obtained without the patient’s consent would have to document this information and its source in the patient’s treatment

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record. Consequently, patients who access their records may feel betrayed when they see a treatment plan based on information they had decided not to share with the psychologist and that may have been inaccurate.

On the other hand, imagine unusual situations in which trying to obtain information on a patient via the Internet may be beneficial. For example, we learned of one situation in which a psychologist greatly feared for the well- being of a highly suicidal patient and, without the patient’s knowledge, looked at his social media postings to gain a better understanding of his degree of risk. Finding even more troubling information there, he moved to intervene more aggressively to protect his patient.

A policy of routinely and surreptitiously searching for patients can be considered from the standpoint of the overall manner in which the psycholo- gist addresses Internet use consistent with overarching ethical principles. For example, Tao (2014) noted that most young adults use social media exten- sively. She discussed how psychologists need to evaluate its use to understand the social connectedness of their patients. She also pursued the issue of the effect of social media on the psychological well-being of patients and whether that should be addressed.

Because the use of social media is a topic for exploration and perhaps for intervention, it makes sense that psychologists should make inquiries regard- ing its use. At the same time, they need to ask themselves if an unauthorized searches of their patients would undercut unique standards of professional psychology, such as the principle of patient autonomy, which, among other things, means that patients disclose private information at their own pace; beneficence, in the sense that patients may learn of the search and perceive it as a violation of trust, or psychotherapists could become “lazy” in their intake because they figure that they can always get the background information through an Internet search; or justice, in the sense that psychologists may choose to search some (types of) patients but not others.

Therapy is most effective when psychologists create an atmosphere of trust so that patients feel free to disclose personal information. Psychologists who wish to use the Internet to learn about their patients could, for example, apply the principle of respect for autonomy by including such information in their informed consent forms and have a conversation with their patients in which they discuss the risks and benefits of doing so. In this way, patients could determine what kind of information therapists may seek and for what purposes. The treatment plan and chart, then, would reflect this understand- ing and the relevance of the information obtained.

Of course, unusual situations may arise in which searching without patients’ consent may be justifiable, such as when one is being threatened or harassed by them. As a general proposition, however, we believe that respect for patient autonomy/beneficence (trusting relationship) and patient profes-

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sional relationships (fidelity) trump presumptive beneficence (accurate infor- mation). Googling one’s friends is common and is considered an acceptable way of keeping up. However, treating patients the same way that one treats friends in this way could be an example of a separation strategy.

TERMINATING THERAPY WITHOUT PATIENT CONSENT

Difficult situations occur when patients want to continue treatment even if they no longer need it, are not benefiting and are unlikely to benefit from it, or are being harmed by treatment. Therapy can be helpful even if patients are not improving if, for example, treatment helps stabilize patients or prevents deterioration. But in some circumstances, therapy can make patients worse. However, psychotherapy may also become a “social habit” without clearly defined goals (Younggren & Davis, 2012, p. 428).

In addition to the ethical issues that arise when fulfilling the obligation to terminate treatment with non-life-endangering patients who are not ben- efiting, especially without their consent, psychologists need to be especially aware of the emotions and potential cognitive errors engendered by their own thoughts. Psychologists do not enter the mental health field to make patients worse or to help them mark time. Hence, it is bad enough to terminate or refer when both the patient and psychologist feel that therapy is not working; however, when patients and therapists disagree, the situation can become much more complex. For example, O’Reilly (1987) described what he called the transfer syndrome, which includes feelings of guilt, depression, and relief on the part of the practitioner. To make matters worse, ethical judgment may be skewed by “fears of evaluation by peers or supervisors, anxiety concerning what the patient might expose about him or her, and anxiety about the new placement” (Rice & Follette, 2003, p. 162).

On the other hand, some patients become reliable sources of income, arrive on time, and are pleasant to work with. In these cases, psychologists need to understand the boundaries and purposes of therapy. It is easy to con- tinue to see such patients, presuming that they would not be coming if they were not benefiting in some way. In such cases, self-interest could influence psychologists to not closely evaluate the patient’s progress. Failing to termi- nate may not lead to extremely adverse consequences for the patient, but it will not necessarily do him or her much good, either.

At the other extreme are burdensome patients who present problems when it comes time to terminate. Often these patients are doing poorly in life. They may be manipulative, engage in self-mutilation or suicidal gestures, and alienate others within their social circles. As a consequence, they have little outside social support and can become excessively dependent on the therapist.

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Of course, such difficult patients may still benefit from treatment, and being difficult is not in itself adequate grounds for termination. Our discussion here focuses on those difficult patients who are not benefiting from treatment and who display behaviors that significantly diminish the likelihood of prog- ress, such as missing appointments and being nonadherent. In more extreme cases, if psychologists suggest termination due to lack of progress, patients may threaten suicide, a licensing board complaint, or the posting of hostile com- ments about the therapist on the Internet. Here is one such case:

A Difficult Patient A patient had developed an extreme transference to the therapist; she

continually solicited her love and became angry when the psychologist got pregnant and had a child (“You love them more than me”). Despite instructions to call only during emergencies, the patient began calling the psychologist at her home at all hours of the day and night for trivial reasons. Frequently, she would miss therapy sessions. The patient also rescinded the release of information form that allowed the psychologist to exchange information with the treating psychiatrist. The patient currently owes more than $1,000 in unpaid bills.

These types of situations may involve a sequential use of proximal qual- ity enhancement strategies and the principle-based ethical decision-making model. Distal quality enhancement strategies are relevant here: Psychologists should try to anticipate that such situations can occur. Several authors have stressed the importance of raising early in the treatment the issues surround- ing termination (e.g., Anderson & Handelsman, 2010; Rice & Follette, 2003; Swift & Greenberg, 2014; Younggren & Gottlieb, 2008). Among other things, as part of the informed consent process, psychologists should discuss what they expect from the patient in treatment and how those expectations relate to termination. The failure to cooperate with the basic elements of treatment, such as arriving on time, not committing a boundary violation, cooperating in therapy, paying bills, and completing homework, should be the basis for discussing the termination of treatment, and, if necessary, reevaluating the treatment plan.

Sometimes psychologists do not like to admit failure and may not be as alert to red flags as they need to be early in therapy. Such early warning signs that treatment may be imperiled include patients who refuse to pay bills or otherwise become nonadherent to treatment recommendations. Such behav- ior can prompt feelings of resentment in the practitioner that may foster non- rational decision making, such as moving to terminate prematurely without adequate exploration of the reasons for the nonadherence.

In Chapter 3, we noted the option of using the four-session rule: If a patient has not improved by the fourth session, or if a good working rela- tionship does not exist, the psychologist can use a prompt list to reevaluate

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the goals and procedures of therapy. Although some psychologists may wait several more sessions before they consider that a treatment plan needs to be reevaluated, we urge a strategy of reevaluating the goals and procedures of therapy early and when the patient is not responding to treatment. The prompt list is an opportunity to consider the four quality enhancement strat- egies: Psychologists may talk to the patient about the lack of progress and solicit input on how to engage the patient in a better way (empowered collab- oration), seek consultation from another professional on the case, document their decision-making process, and seek additional sources of information to determine their progress (redundant protection). It may seem obvious, but the success of these strategies may be greater if they occur earlier in treatment.

If these quality enhancement strategies do not work, psychologists can move to ethical decision-making strategies and weigh patient benefit against the harm of continuing treatment. In the preceding vignette, the patient is not benefiting and even may be suffering harm, but such a conclusion and the termination of treatment may appear to conflict with respect for patient autonomy. The therapist can minimize harm to the offended moral principle by attempting to involve the patient in the discussions “as a matter of respect for the patient’s autonomy and informed consent, to obtain his or her per- spective on the treatment process” (Younggren & Gottlieb, 2008, p. 501).

The psychologist in this case may be influenced by feelings such as anger at the patient, disgust at the patient’s behavior, or anger at herself for not hav- ing enough expertise to help this patient or not knowing better than to have accepted her in the first place. Among the nonrational factors that may exist, the therapist may wish to terminate, but, based on loss aversion, she may act too hastily and fail to follow appropriate professional procedures. Ideally, she would be aware of her feelings and would address problematic patient behavior (including the unpaid fees) early in treatment, instead of allowing resentments to build to a point at which she can no longer stand the patient and begins to worry that she may explode or otherwise act inappropriately toward the patient.

Of course, the situation could be even worse. Consider this example:

A Suicidal Patient A patient was nonadherent to treatment recommendations and was

not making progress when the psychologist raised the option of discon- tinuing treatment. The patient said that this would be so upsetting for her that she would consider suicide. The patient had a long history of passive suicidal ideation but had never threatened to kill herself before.

Here, the psychologist must weigh the ethical principles of beneficence (ben- efit to the patient) with nonmaleficence (avoiding harm to the patient) and respect for patient decision making. One question is whether the threat of suicide is so imminent and serious that terminating the treatment would be

132 ethical dilemmas in psychotherapy

contraindicated. This situation requires a cost-benefit analysis. The psycholo- gist may determine that the threat of suicide is so high that termination should be avoided, at least while the patient is acutely ill. If so, the psychologist may postpone termination to minimize harm to the offended moral principle by continuing treatment as long as the patient meets her obligations, such as keeping appointments, following recommendations, and using on-call ser- vices appropriately. However, the psychologist may determine that the threat of suicide is low enough that the potential benefits of termination and referral are worth the risk of a suicide attempt. In documenting the decision to termi- nate, the psychologist should not deny or minimize the threat of suicide but record the other considerations that balance out the threat.

FINAL WORD

There is no question about the importance of providing informed con- sent to patients. It is legally required, ethically indicated, and it represents a good quality enhancement strategy. Yet some psychologists seem to resist performing this task or taking advantage of all its potential advantages. Some may resent what they consider to be needless legalisms; others may feel that having to address such issues breaks the therapeutic frame and intrudes on the process. Although we understand how some of our colleagues may feel, we hope this chapter shows that attending to informed consent can not only meet legal standards but can also be a matter of excellent clinical care.