Consider the following case:
You are a new, qualified, dedicated, psychotherapist. During your first session with a new client, Joan, she tells you she was previously in therapy with a psychologist, Dr. Lee Beedo. A few minutes later, she tells you she and Dr. Beedo had sexual encounters during the treatment. You tell her sex between therapists and clients is forbidden and that she should file a complaint. She tells you she is not interested in filing a complaint—she just wants to move on and doesn’t want you to talk to anybody, either. What do you do in this case?
Thinking through cases and dilemmas such as this one is a great way to study ethical decision making and behavior. Many authors have developed step-by-step procedures for making ethical decisions (see Cottone, 2012, for a review). One important step in any decision making process is to generate possible courses of action. As you review the case of Joan, how many potential courses of action did you think of? Here are a few options my students often suggest:
- File a complaint against Dr. Beedo yourself, perhaps anonymously.
- Talk to Dr. Beedo and warn him not to have sex with any more clients.
- Tell Joan she has to report the incident (to the State Board, to theAPA Ethics Committee, and to her state psychological association ethics committee if there is one in her state) to protect other potential victims; otherwise you won’t see her in therapy.
Another element of ethical decision making is to consult the APA Ethics Code (http://apa.org/ethics/code/index.aspx). In the APA Code, we find that sexual relationships with clients are forbidden by Standard 10.05: "Psychologists do not engage in sexual intimacies with current therapy clients/patients.” Thus, if Joan’s allegations are true, Dr. Beedo has indeed acted unethically.
The APA Code also includes guidance about what to do if we know a colleague has acted unethically. Standard 1.04 says, in part, "When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate.” According to this standard, going to see Dr. Beedo and sharing our concerns looks like a good idea. However, sex with clients is so serious and potentially harmful (Pope, 2002) that an informal resolution is inappropriate. This is covered in Standard 1.05, which tells us, in part:
If an apparent ethical violation has substantially harmed or is likely to substantially harm a person…and is not appropriate for informal resolution under Standard 1.04… psychologists take further action appropriate to the situation. Such action might include referral to state or national committees on professional ethics, to state licensing boards, or to the appropriate institutional authorities.
According to this part of Standard 1.05, we should report this alleged violation, right? Most of my beginning ethics students want to report Dr. Beedo, perhaps out of a sense of duty and/or moral outrage. However, there’s one more surprise in store: the principle of confidentiality. Joan shared this information as a psychotherapy client, and we are therefore obligated to maintain her confidentiality—to keep what she says private. The next statement in Standard 1.05 reads: "This standard does not apply when an intervention would violate confidentiality rights.” This confidentiality element also applies to Standard 1.04.
Our obligation to maintain confidentiality is so important that it outweighs our obligation to report in this case. We cannot even share the identity of our client without her consent, and we cannot report Dr. Beedo anonymously because there would be no way for a committee or board to investigate without violating confidentiality.
But, can we speak with Dr. Beedo and just say, "One of your clients has accused you of sexual misconduct”? The answer is no because we would still be using information we obtained in a confidential relationship. It’s possible, for example, that this client was the only one with whom Dr. Beedo had sex. Thus, we would be breaching confidentiality by disclosing the identity of our client.
Then what can we do? One crucial action would be to discuss with the client her options of filing ethical and/or legal complaints. However, we would be careful not to put undue pressure on her to take action because our primary concern is the welfare of our clients.
Many students are frustrated at this point in the discussion—they would like to take action to protect other potential victims and see that justice is served. I use students’ frustration to help them understand how critical confidentiality is in establishing a trusting psychotherapeutic relationship. Driscoll (1992) referred to confidentiality as a "sacred trust” (p. 704). However, there are exceptions even to such an important principle as confidentiality. In some situations therapists are obligated to break confidentiality. We’ll be exploring these exceptions to the principle of confidentiality in future columns.
Cottone, R. R. (2012). Ethical decision making in mental health contexts: Representative models and an organizational framework. In S. Knapp, M. Gottlieb, M. M. Handelsman, & L. VandeCreek (Eds.), APA handbook of ethics in psychology: Vol. 1. Moral Foundations and Common Themes (pp. 99–121). Washington, DC: American Psychological Association.
Driscoll, J. M. (1992). Keeping covenants and confidences sacred: One point of view. Journal of Counseling and Development, 70, 704–708.
Pope, K. S. (2002). Sex between therapists and clients. In J. Worell (Ed.), Encyclopedia of women and gender: Sex similarities and differences and the impact of society on gender: Vol. 2 (pp. 955–962). San Diego, CA: Academic Press.