Hot Topics in Interpersonal Violence: Positive Ethics in Therapeutic Practice, Consultation and Interventions
Linda K. Knauss, Ph.D., ABPP
Jeanne M. Slattery, Ph.D.
Thursday, June 16, 2016
Mr. Thompson’s Confession[1]
Dr. Murphy has been treating Mr. Thompson in private practice, as an outpatient, for the past three months for depression. It has been very difficult for Dr. Murphy to really get a handle on what is causing Mr. Thompson’s depression. In the most recent session, Mr. Thompson asked Dr. Murphy if he remembered the highly publicized case of Audrey Brown, a young woman who had been killed three years ago, where the murderer had never been caught. Mr. Thompson confessed that he murdered Audrey and is depressed because he feels great remorse about it. He would like Dr. Murphy to help him feel better about this. He does not want to confess his crime to the police, because he does not want to be incarcerated, much less receive the death penalty. He tells Dr. Murphy that he has no intentions of harming anyone else in the future, and is at no risk of harming himself.
Dr. McLeod, the Searching Psychologist[2]
Dr. McLeod has been asked by the Board of Teaching to conduct an assessment of William, a 24-year-old high school teacher. William was recently suspended from his job following reports that he had been sending sexually inappropriate e-mail messages to students. The referral letter included copies of the e-mails and a summary of the complaints from students’ parents.
The significance of this evaluation weighs heavily on Dr. McLeod. It is possible that William is really a good teacher whose youth, inexperience, and transient life stresses have corrupted his normally solid professional judgment. Yet, she is haunted by the alternative hypothesis: that William is a predator, at risk for using his teaching position to access and abuse children. Overestimating his pathology may result in the unnecessary destruction of his fledgling career, yet underestimating it risks harm to children.
Compelled by the gravity of this assessment, Dr. McLeod decides to see what information she can find online. A Google search locates William’s Facebook page. Surprisingly, he allows open access to some of his information – including his list of Facebook friends. She scans the list and discovers that her brother Jim, an adult, is pictured there! This discovery further piques her curiosity about what else she might be able to learn to help her prepare for the interview.
She secures her brother’s permission to use his Facebook account to assist her with “a very important teacher evaluation,” but is careful not to mention the name of the person she is researching. William’s Facebook page reveals that he is a youth group leader in his church, and that he coaches a community lacrosse team for teens. Several of the pictured friends appear to be younger than 18, but their ages are uncertain. Dr. McLeod finds many links on William’s Facebook page to YouTube videos that include nudity and sexual humor.
The interview with William is frustrating for Dr. McLeod. She inquires about his avocational activities, and he fails to mention coaching or running a youth group. Nothing in his presentation suggests any proclivity for sexually inappropriate activities or humor. Ultimately, she is unable to resist confronting him about what she has discovered on his Facebook page. William responds with anger and says that she has a completely distorted perception of him. He demands to know how she was able to access his private information and why he was not informed about this in advance. Dr. McLeod equivocates and concludes the interview early. She immediately regrets disclosing what she found and resolves not to mention her Internet search in the final report.
Later that day, she receives a message from her brother, Jim. He has reviewed the history of his Facebook activity and saw that she accessed information about William. Jim says that his son, Dr. McLeod’s nephew, is on William’s lacrosse team, and he just wants to know that he will be safe with William.
Panicked and confused about how to proceed, Dr. McLeod contacts you for a consultation.
The Near Death of a Salesman[3]
Dr. Miller is a psychologist who consults with local nursing homes and hospitals when a patient’s capacity to make medical decisions is in question. Dr. Miller receives an urgent call from an attorney to evaluate Willie Loman at a local trauma unit. The attorney explains that Mr. Loman is looking for an objective opinion about his ability to make medical decisions.
Mr. Loman is a 52-year-old male with a wife and two children (both in college). He works as a financially successful salesman. Over the previous weekend, Mr. Loman was involved in a serious boating accident. He did not experience any head trauma; however, his physical situation was dire. The trauma team needs his consent to perform a lifesaving surgery. If successful, Mr. Loman can live many years. However, there is a high probability that he will require full-time nursing care.
Mr. Loman has been active man who enjoyed many physical activities. Furthermore, he believes if he has the surgery and ends up in long-term nursing care, he will exhaust the funds he has saved for his family. Mr. Loman believes he will become an emotional burden to his family and lose his dignity. Knowing that he will be physically compromised and a burden on his family, Mr. Loman is asking to die in peace. He does not want to live "like that."
Without the surgery, Mr. Loman can be kept alive for about two weeks. The family filed an emergency petition to obtain guardianship. The trauma team believes that the patient is not thinking clearly about his demise. They have already called in their psychiatrist-consultant.
Upon examination, Dr. Miller finds Mr. Loman’s mental status is within normal limits. He demonstrates appropriate memory capabilities and reasoning skills. He articulates his dilemma well and understands that he will die without surgery. There is no evidence of hallucinations, delusions, or psychotic processes.
In order to clarify his thinking, Dr. Miller calls you to review this case.
A Question of Impairment[4]
I work in a relatively urban setting, with a population of approximately 45,000. There is a small but vibrant community of psychologists here and we have formed a local affiliate of our state psychological association. We generally schedule four meetings a year. Our meetings serve multiple functions: to review the association’s agenda, network and make referrals, meet and greet new members, and catch up with one another’s personal news.
One of our members, Dr. Brevard, is a psychologist in his early fifties whose work is split between psychotherapy and forensic evaluations (mostly child custody). His workshops on child custody have been among the best attended at state conferences. Dr. Brevard has increasingly seemed in distress over the past several meetings. Three meetings ago – our summer meeting – he mentioned that he and his wife had separated. He seemed preoccupied and drank enough that one of our other members offered to give him a ride home, which he accepted, but only after the person parked behind him agreed to move her car conditional on his not driving that evening. At the fall meeting, after two or three glasses of wine, he became weepy when asked about his daughters who, he explained, were spending school nights with their mother. At the holidayparty, which took place on a Saturday evening, he had enough to drink that his gait became unsteady and he was heard to mutter “that bitch” under his breath when referring to his daughters spending the holidayswith their mother. Recently, when a member of our group ran into Dr. Brevard at a local café during a weekday lunch hour, it seemed to her that he had been drinking and heappeared somewhat unkempt – his professional appearance was usually impeccable.
Our state hasa statutemandating reporting impaired health professionals. Our state psychological association has an impaired psychologist committee.
Safety Takes a Holiday
White Pines is an agency specializing in work with high-risk and dangerous clients. They work very hard to offer state-of-the-art trainings on violent clients, travel frequently to present on issues of violence, and often serve as expert witnesses on issues of domestic violence, sexual assault, and child abuse.
The staff supervises a large number of interns and post-docs at their site, although often find themselves cancelling supervisions and squeezing supervisions in between other obligations. Court appearances often run long andstafffrequently get called in by the police for consultations.
Dr. Smythe, a new post-doctoral intern, has not worked with this level of violence in the past and often feels unsafe – both with specific clients and in general at the agency. She talked about this with her fellow interns, some of whom raised similar issues. When she raised this with Dr. Wesson, her supervisor, he dismissed her concerns. He suggested that she has nothing to worry about, as all visitors must go through a metal detector before being buzzed into the building. He then ran off for another evaluation. Dr. Smythe felt belittled by this conversation and didn't raise her concerns again – nor didher supervisor. In fact, there is little training on the roles of emotional and physical safety with these populations. Dr. Smythebelievesthat the agency's philosophy is that staff should "suck it up" rather than express concerns.Dr. Smythe continued to feel unsafe and began to experience occasional panic attacks.
Dr. Smythereturned to see her old therapist, Dr. Lopez. He suggested that one of the things that she might do is carry a small handgun in her purse.
A Suicidal Client's Gun
Ms. Jones has been licensed and in private practice for 30 years. She is experienced with guns and, in fact, offers a gun safety course for her community.
She recently had a 14-year-old client, Salem, who reported that he wanted to kill himself. He reported having a plan (shooting himself), and noted that he owned a rifle and planned to use it when his parents left town that weekend.
Not surprisingly, Ms. Jones was very worried. She believed that he was at high-risk of acting on his suicidal intent, as assessed depression was very high and he had a history of previous suicide attempts in the last year. He refused to go into the hospital and said that he would deny suicidality if he were forced into the hospital. He also said that he would refuse to return to therapy if she attempted to hospitalize him. Ms. Jones attempted to get Salem to give his gun to his parents, but his relationship with his parents is very contentious and discussions often escalate into physical altercations and threats.
Salem did agree to give Ms. Jones his rifle. He also agreed to daily phone calls and more frequent therapy appointments.
While she is meticulous in caring for her own guns, Ms. Jones did not have a gun safe in her office. As a result, she put his rifle behind the couch in her office.
While she was out of the office copying paperwork, one of her child clients found the rifle and pulled it out. When she walked back in the room, this child was pointing the rifle at her, although apparently without intent to harm her (he was treating it as a toy).
A Duty to Report?[5]
Dr. Tell worked with a woman for several months on issues related to depression, anxiety, and relationship issues. During one session, the patient indicated that her boyfriend has lost interest in sex and became more involved with online pornography. While discussing these issues, the patient suddenly stopped talking. Dr. Tell allowed several moments to pass before asking the patient what was happening.
The client indicated that she was hesitant to speak about the issue for fear of a breach of confidentiality. Dr. Tell reminded her about confidentiality and the laws in Pennsylvania that would override it. The client continued to struggle. She eventually blurted out that, during a heated discussion, her boyfriend indicated that looking at online pornography was not as bad as what his uncle did. She went on to detail how her boyfriend described how his uncle was involved in collecting and distributing child pornography but remained faithful to his aunt. The client's boyfriend expressed that she should never discuss this with anyone. The client asked if she could just give Dr. Tell the information about the uncle so that she could report it to the authorities and leave her out of the situation. The client is feeling very helpless and vulnerable about this bind.
Dr. Tell explained that the alleged perpetrator was several times removed from their sessions and she did not believe that she had the obligation to report it. The client then asked if she could invite her boyfriend to the next session so that they could all discuss the information and the best way to handle the situation.
Dr. Tell focused the client on her dilemma as well as the relationship issues with her boyfriend. Dr. Tell agreed to contact someone to discuss whether Dr. Tell had to report this information to the police or Child Protective Services. And, Dr. Tell agreed to determine whether or not reporting this information would put her client’s confidentiality at risk. She also agreed to think about the need to bring in the boyfriend, because inviting him to therapy will not necessarily help the situation.
Dr. Tell contacts you with the above scenario.
Megan’s Law
Dr. Phillips is a forensic psychologist who has a varied forensic practice. He does custody evaluations, assesses individuals for competence to stand trial, performs risk assessments, and recommends level of treatment among other services. Many of Dr. Phillips' clients are accused of sexual offenses, including child abuse, and at times he re-evaluates clients who are registered as sex offenders under Megan’s Law.
Recently Dr. Phillips moved to a new office. He is very happy with the location of his new office, it is handicapped accessible, he has more space, and the rent is very reasonable. Dr. Phillips also likes his colleagues in this office. One of the other therapists in his new office is a child psychologist and there are often children and families in the waiting room along with his clients. Dr. Phillips is beginning to worry that this may be a dangerous situation and is wondering what his obligations may be to protect the other clients.
50 Shades of Gray
Mr. Newbie, an intern, has accepted a new client, Senator Gray, who is a major politician in an adjacent state. She sought Mr. Newbie out primarily because he was out-of-state, but also because his office is near an area where she likes to find hook-ups – to "unwind."
Senator Gray gradually discloses an ongoing interest in bondage and S & M, which increasingly disturbs Mr. Newbie, as she describes increasingly lurid fantasies about hurting or humiliating unsuspecting women who she picks up in a local bar. Mr. Newbie gradually comes to believe that a series of assaults reported in the newspaper were, in fact, committed by Senator Gray.
Mr. Newbie is a relatively new therapist with little experience in such issues. He is confused by the range of feelings he has about her – admiration of her career, abhorrence of her actions, and lurid curiosity. He wants to consult a colleague about this case, although Senator Gray refuses permission, even if her identity is masked.
Senator Gray wants to use her insurance, but doesn't want anything in her chart or diagnosis that would suggest the sorts of issues being discussed. In fact, when she first came in, she attempted to seek services using her assistant's name and insurance information.
[1] This vignette was written by Dr. Elizabeth Foster.
[2] This vignette was based on a vignette written by the American Psychological Association Ethics Committee.
[3] This vignette is from the Pennsylvania Psychological Association website.
[4] This vignette was based on a vignette written by the American Psychological Association Ethics Committee.
[5] This vignette is from the Pennsylvania Psychological Association website.