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Ethical Dilemmas

By the OSP Ethics Committee

This article first appeared in the Winter 2015 issue of prOSPect

The opinions expressed in this column do not necessarily represent the views of the OSP Board or committees.

Dilemma:
A flattering request

I have received a message from a former client who terminated a year ago, after two years of therapy. The issues addressed in the therapy included childhood sexual abuse and, while at the time I felt the client had made good progress in coming to terms with these traumatic events, in my view the termination (which she had said was due a combination of financial pressure and her belief that she was ready to move forward alone) was premature. In her message, she tells me that she has been attending a creative writing group and has been writing about her memories of abuse. Her teacher, a well-known local author, has praised her writing for its power and style and believes it could make a marketable book. My former client, who knows that I have published widely on professional topics, asks if I would consider being a joint author. I am flattered by the request and intrigued by the potential opportunity, but unsure about the ethical implications. How should I proceed?

Let us know how you would respond in this situation. If you have faced a similar situation, please tell us about it and what you did. Submissions may be edited for space reasons and will be published anonymously. Or submit a thorny ethical scenario that you would like to see featured in a future column. Please send your responses to mail@psychotherapyontario.org.


Responses to the Spring 2014 Dilemma — I’m Afraid My Office Is “Bugged”

Background: In the last issue’s dilemma a client had disclosed that his apartment was infested with bed bugs. He was distressed and felt ashamed. The session was spent discussing these issues and the therapist gave him practical advice on tackling the problem, but avoided bringing up the risk of his infesting her office. Afterwards, she found herself both anxious about the risk of infestation and unsure how best to approach the issue with the client.

Response #1:

This is an exceedingly difficult dilemma and makes me think about what one would do about a client who had lice, fleas or scabies. Can one really guard against these things without deeply humiliating clients? On the other hand, one can’t take the risk of infecting other clients.

It makes me think of former clients who have done such things as wiping sweat off their foreheads onto the arms of my couch, or making careless pen marks on my upholstery during sessions. In these cases, I have spoken up (gently) to request a change in behaviour. But the matter of infestation is quite another thing — once the person has been in your space, there’s every chance that they’ve handed their problem to you.

Perhaps the only thing to be done is to contact the infectious person after the fact, tell them that you have had to take steps to de-infest your office and that you won’t be able to see them again in therapy until they have taken similar steps, while reassuring them that this is a purely practical matter and nothing to do with your willingness to continue to see them. In other words, destigmatize the infestation, emphasizing that it can happen to anyone and is not about any person’s intrinsic worth.

Response #2

First, without telling the client I would find out the risks of an infestation and how to prevent it. I feel that it is the therapist’s responsibility to find this out before raising it with the client and taking the necessary steps. If it became clear that the client needed to be spoken to, I would do what I could to avoid bringing my own anxiety into the room. It would be important to ensure that the client has addressed the practicalities in a satisfactory way, and to discuss ways not to spread the infestation, when the client is calm.

Response #3

It would be necessary to balance sensitivity to the client’s feelings of shame about his bed-bug situation with your need to protect your office from infestation. It could cause deep damage to the client’s self-esteem — and to the therapeutic relationship — if the communication were handled clumsily. But, on the other hand, there is no benefit in pussyfooting around the issue: it needs to be tackled head on.

I would call the client and, first, check in with his feelings about the last session, since it appears to have been a difficult issue to disclose and discuss. I would keep to myself any concerns that the office might already be infested — if it is, that is my problem to deal with and it will do neither the client nor me any good if he learns about it.

About the possibility of future infestation, I would say something to this effect: “One of the things that occurred to me after our meeting is to wonder whether it would be possible for you to be carrying the bugs on your clothes. Have you looked into that? If that’s a possibility, it might be best if we were to find an alternative way to meet for the next week or two, such as a phone session. I know this is a difficult topic and certainly don’t want to make you feel worse, so I’m very open to hearing your feelings about this suggestion.”

Assuming the relationship was strong enough to contain this suggestion and the unpacking of the client’s associated feelings, I’d continue to invite the client to process it through subsequent sessions. Hopefully, it may eventually become something that therapist and client can smile about together, once the situation has passed.

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