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1. An attorney refers many clients to you for psychological evaluations. A close friend of yours has retained this attorney, who refers your friend to you for a very important psychological evaluation. The attorney tells your friend that you are the best and the best is needed in this case. You are strongly encouraged by both the attorney and your friend to do the evaluation.

I think as a psychologist I am obligated to avoid any relationship , such as friendship, that might impact my professional judgement. I can think at least two ethical constraints are at play in this situation. 1. Conflicts of interest 2. Dual or multiple relations. 1. Conflicts of interests are situations in which individuals have interests that significantly threaten their role and responsibilities. With regard to professional conflicts of interest, it is suggested that the person in question is licensed to make a judgment by virtue of the individuals professional status and that the individual is then accountable to others within and outside his/her profession for that judgment. (APA2002:3.06) Conflict of Interest: Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or expose the person or organization with whom the professional relationship exists to harm or exploitation. This ethical guideline is one good limitation and justifies the conflict of interest clause in this situation 2. A dual role relationship exists when an individual simultaneously or sequentially participates in two role categories (Kitchener, 1986). Carroll, Schneider & Wesley (1985) concluded that a dual relationship exists when, in addition to the professional relationship, there is some other relationship with the individual: friend, family member, student or business partner. Problems with dual relationships may be explained by role theory. Social roles contain inherent expectations about how a person in a particular role is to behave as well

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as the rights and obligations which pertain to that role. Role conflicts arise when the expectations attached to one role call for behavior which is incompatible with that of another role (Kitchener, 1988). Roll & Millen (1981) developed guidelines for psychologists who must respond to requests for psychotherapy from acquaintances. They included: avoiding doing so if possible, remaining mindful of possible transference relationships, obtaining consultation, maintaining boundaries, being aware of one's own values, being prepared to lose the friendship, remaining mindful of confidentiality, recognizing when treatment should be terminated, and insuring that the therapist's personal needs are met to avoid abusing the psychotherapy process. As a psychologist, I may lose sight of the true motives behind the attorneys referral. 3.05 Multiple Relationships

A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the

same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologists objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has

arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.

When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in

more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and

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the extent of confidentiality and thereafter as changes occur. (See also Standards 3.04, Avoiding Harm, and 3.07, Third-Party Requests for Services.)

APA : Ethical Principles of Psychologists and Code Of Conduct 2002

2. You have a client who has adjusted a very busy schedule in order to be able to attend therapy sessions. You cancel a session to attend a funeral for a family member. The client becomes irate and demands to be told the reason why you cancelled.
As a first step. I need to apolozise to the client about the cancellation and I recognize the need to calm the client. When a person becomes irate, that is part of anxiety (hyperarousal). Anxiety, agitation and aggression are spectral. I need to recognize even though client was informed about my non-availability, probably that was not sufficient for this client who had to adjust schedule and needed the therapy .He felt slighted and that caused him irritation. I probably will inform him the reason .

As a clinical psyhchologist I need to recognize my own countertransfererence and how some of my feelings might either help or hinder my ability to understand and work with this client and I need to be aware of the cultural dimemsions of how client expresses himself. Therapist needs to be aware of unresolved personal issues (in this case , may be grief). It is a must that I aquire awareness of my personal needs and my own unresolved personal conflicts. For example, if I am intimidated by a client s anger because my unresolved feelings concerning anger, it will be most difficult for me to facilitate the exploration of anger on the client s part. Some of my clients may respond to me through the transference. A key ethical area is recognizing how my needs of personal conflicsts may get in the way of dealing with this client. Heightened emotional arousal makes most clients vulnerable to further arousal, biased thinking, and countertherapeutic behavioral actions.

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3.12 Interruption of Psychological Services Unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist's illness, death, unavailability, relocation, or retirement or by the clients/patients relocation or financial limitations. 3. The partner of a client who you have been treating for severe depression sends a letter to you. Should you open and read it? There are many ethical issues to be considered in this case. The primary issues are confidentiality , informed consent, and working with multiple clients. Confidentiality is both ethical obligation and also problematic. It is important that not all share the individualistic notion of personal privacy. Some clients infact may want the confidential information shared with their partner, family or even community. Of course, this is a multicultural issue as well. Therapist might want this information settled in the first meeting so that it can be incorporated in the informed consent to avoid problems . Confidentiality belongs to client not to therapist. Sometimes a partner might want to start therapty with living partner; This creates dual relationship however. Then it is up to the therapist to discuss personally in the presence of both partners but not through this envelope. Informed consent issues are to be considered when applied to treating more than one client and sharing the clinical information with the spouse or living parnter. Informed consent is very important because the partner of the client may want to be a client and then there is dual relationship which may or may not be in the best interest of either client. This type of relationship involves risks and responsibilities that are different than individual psychotherapy. In this kind of a situation, there is a high possibility of developing boundary issues. Since the informed consent has been made earlier with this client and probably did not involve the partner, It is not in the best interest of my client that I probably should open the envelope.

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Multiple Relationships with clients, at the outse, a professional must address whether he or she even needs to enter into a dual relationship. Simply put, unnecessary dual relationships can be fraught with unnecessary risk. As a rule, it is likely to be in the best interests of the professional, regardless of location, to avoid dual relationships of this type if at all possible. Therapist who chooses to enter into a dual relationship with a client, or one who is even forced into the dual relationship, must manage the relationship in such away that the therapeutic component is not damaged by the secondary relationship. In this spirit, the therapist has an obligation to discuss this factor in detail with the patient prior to entering into the dual relationship if any is forthcoming and must also keep this topic and related issues at the forefront of treatment to avoid any damage to the therapeutic alliance.

APA : Ethical Principles of Psychologists and Code Of Conduct 2002

4.01 Maintaining Confidentiality Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.
3.05 Multiple Relationships: A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologists objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. 3.10 Informed Consent (a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Co

Page 6 (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.) (b) For persons who are legally incapable of giving informed consent, psychologists nevertheless (1) provide an appropriate explanation, (2) seek the individual's assent, (3) consider such persons' preferences and best interests, and (4) obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. When consent by a legally authorized person is not permitted or required by law, psychologists take reasonable steps to protect the individuals rights and welfare. When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, 4. You have worked for several years with a man who has a history of rejection by women. He has worked through many issues and finally has a suitable and loving relationship. He is very grateful to you and strongly encourages you to attend the wedding.

a. If you decide not to attend, how would you address this with your client?

The codes are silent with regard to having a social relationship with a former client. Although engaging in social relationships with former clients is not necessarily unethical, the practice may be unwise. It is probably best to exercise caution before entering into such a relationship, even alter termination. In the long run, former clients may need you at some future time as their counselor than as a friend. If you change the professional relationship to a personal one, you close the possibility of the client returning to you to counseling services at later time. A therapist has to take into account the entire therapeutic relationship before deciding to engage in any extra-office contacts (Brown, 1994) b. If you decide to attend, how would you address this with your client and at the wedding? We have make a difference between boundary crossing and boundary violation. Often, boundary crossings with good intentions can be beneficial and even required and therapeutic in most cases at the discretion of well intending therapist whereas boundary violations are mostly harmful. In my opinion if I decline his invitation , even with unduly polite and genial, this could have reinforced his rejection attitude even slightly and my acceptance gives him a push therapeutically. I think the government and professional bodies instead of focusing on the exploitive nature of the relationship and try to take preventive steps, focus very negatively on should nots and punishments too much and I think that is very negative attitude. I will look if the border crossing is beneficial to my client and then I will go along and accept , if not , I wont.

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In this case, it is important to see there are some underlying clinical issues in the clients request Hopefully , the therpy tour is a laboratory where clients learn how to engage in life. ReaL living is supposed to occur beyond the therapy venture. 5. A client has a terminal disease and has decided to stop treatment and all heroic measures. This type of suicide can be called rational suicide. Rational suicide means that a person has decided after going through a decision making process without coercion from others to end his or her life because of suffering associated with terminal illness. Intellectually I agree with the the option with a premise that individual should have a right to make that decision when they are terminally ill. Of course there are guidelines (Werth 1996) exploring the person with free will, without outside pressure and assessment of mental competence including, religious and medical professionals . Religious organizations are vehemently opposed to the concept itself. Based on Oregon example, psychological assessment may be needed in all cases to rule out depression. But it is catch 22. How many people with terminal illness are totally depression free? Psychologists involved should be familiar with various issues related to patient, illness, terminality, quality of care they are receiving on and on ..National Association of Social Workers is the only organization as of now developed a policy statement related to the end of the life decisions (1994a). Eventhough 80% of professionals from support rational suicide, they still need to struggle between ethical and legal Chasm. This is one area we can see the gulf between ethical principles and legal mandates. I gave a table down which shows, malpractice law suits are 3 times more associated with suicides than associated with psychopharmacology approach(drugs). Following strictly legal path, therapist will be free from malpractice but the question is , will it work? At this point that is the only option open, otherwise legal ramnifications are very high. Recent allegations of malpractice (approximate frequency of claims) Allegation Incorrect treatment Attempted/completed suicide Incorrect diagnosis Improper supervision Medication error/drug reaction Frequency, % 33 20 11 7 7

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Improper commitment Breach of confidentiality Unnecessary hospitalization Undue familiarity Libel/slander

5 4 4 3 2

Other (e.g., abandonment, electroconvulsive therapy, third party injury) 4 Source. Data from Benefacts 1996.

6. You treated a Native American for alcohol use/abuse several years ago. When you and some friends go to a casino for a weekend, you encounter this person who tells you and your friends that he now has a good job at the Casino thanks to the work he has done with you. When you go to check out, you are told that your room and dining expenses have been compd.

One may think that accepting a gift is a plain matter. Some may convey the message to a client that they cannot accept gifts or any related activities. because doing so might be viewed as unprofessional. From a legal prerspective, accepting gifts from clients, especially expernsive ones is risky. If you do accept a gift., it may be a good idea to document your clinical reasons for doing so. However, from a multicultural perspective, gift givingmay b a common practice in some cultures including native Indian culture(ACA 10e) Ragardless of your decisin, it may be necessary to explore the clinical dimensions involved. What are his motives for wanting your room paid . There are several types of gifts that are common in psychotherapy. Gifts can be given by therapists or clients. They can be symbolic (i.e., a poem) or concrete (i.e., a book) and they can be modest - homemade cookies or bread, a music CD, flowers, homegrown fruits or a framed picture - or more extravagant items, such as opera or baseball season tickets, or even truly excessive items like a piano, a car or a large sum of money (Knox, et. al., 2003). Gifts can be appropriate or inappropriate in their type, monetary value, timing, content, frequency, intent of the giver, perception of the receiver and their effect on the giver, receiver or anyone else that may be touched by the gift-giving (Knox, et. al., 2003; Spandler, et. al., 2003) . Appropriate gift-giving, by either clients or therapists, falls under the definition of boundary crossing. Inappropriate gifts, such as very expensive gifts or sexually suggestive gifts (i.e., pornographic images, dozen red roses), are

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clearly boundary violations. Dual relationships involve the therapist in relationships that are additional to the therapeutic one. I consider this payment is inappropriate and might decline. 7. A female client reports sexual abuse by another therapist. When you encourage her to report this, she indicates that she wants you to do this, as she does not want to get the other therapist in trouble.

Legally this is a reportable case. Three types of legal responses to sexual misconduct have been enacted: 1.reporting, 2.civil liability, and 3.criminal prosecution. Reporting statutes require a therapist who learns of any past or current therapistpatient sex to disclose this information. Some states have enacted civil statutes that make it explicit that sexual misconduct is a violation of the standard of care and authorize a damage claim (Bisbing et al. 1995). Criminal statutes addressing sexual misconduct have also been enacted. They may be appropriate given the therapist's behavior and may be the only remedy for exploitative therapists who do not have malpractice insurance, therapists who are unlicensed, or therapists who do not belong to professional organizations.

Therapistpatient sex is usually preceded by progressive boundary violations in treatment (Simon 1989). As a consequence, patients are often psychologically damaged by the precursor boundary violations as well as the eventual sexual misconduct of the therapist (Simon 1991). An excellent account of the gradual erosion of treatment boundaries leading to near loss of control with a client is given by Rutter (1989). Sexual misconduct does not occur in isolation but usually involves a variety of negligent acts of omission and commission.

8. A fragile female client who believes that she has made great progress would like to enter a training program to become a mental health professional. The client wants you to write a letter supporting her entrance into a training program. You are not sure she is sufficiently mentally healthy to work as a professional.

A letter from a therapist is not a good idea. It will not help application. Recommendation letters speak to the student's academic competence. Effective letters are written by professionals who have worked with the person

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in an academic or professional capacity. Helpful letters discuss specific experiences and competencies that support an applicant's preparation for the academic and professional tasks entailed in graduate study. The graduate admissions committee will deem a letter from therapist as inappropriate as it's based on a therapeutic relationship rather than an academic relationship. Second this is a border crossing issue(.Lazarus 2002) .

In otherwords, even if she is sufficiently mentally healthy to work as professional, still it could have been a border crossing issue. It is a bad idea here because if therapist volunteers and writes a honest letter , that will not serve the client well and that would work against her admission. That will have an adverse effect on the therapist-client relationship. If therapist goes ahead and gives her An inflated recommendation letter when she is not really sufficiently healthy to work as a professional, he or she is misrepresenting the mental status of the client and that is unethical clinically as well and may lead to lot of other problems (APA .05 Multiple Relationships) 9. You have a private practice and teach graduate students who are studying to become mental health professionals. You are approached by a student in the last class in the program with a request to begin individual therapy with you. Certainly combining academic and professional relationships with current students is problematic at best, forming professional relationships with former students may be aceptable after termination of the academic relationshipIt is best to keep relationships with students on a acadamec field alone , which can be done by not combining professional and academic relationships The codes are silent with regard to having a professinal relationship with a former student. Although engaging in professinal relationships with former students is not necessarily unethical, the practice may be unwise. It is probably best to exercise caution before entering into such a relationship, even after student completes the training.

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Forming profesional relationships with current students is but one example of a dual relationship. Learning to deal with dual or multiple relationships isessental if you are to practice ethically (APA .05 Multiple Relationships)

10. You have worked with a client who is a fellow professional. You both agree that you have much in common. The client has made excellent progress, and has terminated therapy. What should you do when, shortly after treatment has terminated, the client calls and suggests that you purchase season tickets for a series of theatrical performances?