Midterm - Conflict of Interest, Boundaries, General Conduct

Question 1

AAMFT Standard III - Professional Competence

Answer 1

3.4 Conflict of Interest: do not provide services that create a conflict of interest that may impair work performance or clinical judgment
3.7 Harassment: do not engage in sexual or other forms of harassment of clients, students, trainees, supervisees, employees, colleagues, or research subjects.
3.8 Exploitation: do not engage in exploitation of (as above)
3.9 Gifts: attend to cultural norms when considering the potential effects that receiving/giving gifts may have on clients and the integrity and efficacy of the therapeutic relationship

Question 2

AAMFT Standard VIII - Financial Arrangements

Answer 2

8.1 Financial Integrity: do not accept/offer kickbacks, rebates, bonuses or other remuneration for referrals. Fee-for-service arrangements are not prohibited
8.2 Disclosure of Financial Policies: clearly disclose all financial arrangements before entering the therapeutic/supervisory relationship
8.4 Truthful Representation of Services: represent facts truthfully to clients, third-party payors and supervisees regarding services provided

Question 3

Questions to consider before accepting/rejecting/offering a gift

Answer 3

• What is the monetary value of the gift? (is it under $20?)
• What are the clinical implications of accepting or rejecting the gift?
• When in the therapy process is the offering of a gift occurring? (more appropriate at termination than outset of therapy)
• What are the therapist’s motivations for accepting or rejecting a client’s gift?
• What are the cultural implications of accepting/rejecting/offering a gift?
• What is agency policy?
• How will you document the accepting/rejecting/offering of a gift? (anything received must stay in client file - or a picture of it must)

Question 4

Monetary Conflicts of Interest

Answer 4

• Receiving a benefit from third-party payor
• Accepting materials or equipment
• Getting deals on premises or equipment
• Revenue sharing arrangements
• Selling or recommending products

Question 5

Questions to ask when considering treating a client’s friend or family member

Answer 5

• How close is the relationship?
• How stable is the client emotionally/in relationships?
• Can you stay objective?
• Can you uphold confidentiality of both parties?
• Is there risk of ‘collateral information’ that could be significant?
• How will you manage if entering into conflictual content? (e.g. steer conversation/re-direct)
• Are other services available?
• What things could change that might make it more difficult to maintain objectivity?
• What is your plan if a conflict of interest does arise?

Question 6

Role of Boundaries in Therapeutic Relationship

Answer 6

• A therapeutic frame that defines a set of roles for the participants in the therapeutic process
• A foundation for this relationship to ensure a sense of safety and the belief that the clinician will always act in the client’s best interest
• A distinction between the expectations and interactions that would be considered appropriate within the relationship and those that would be inappropriate within the relationship

Question 7

7 Common Boundaries in Therapy

Answer 7

1. Touch
2. Time (e.g. not going over session time limit, hours can contact therapist)
3. Space (e.g. respect for therapeutic space, personal space - where can sit in room, what can touch, etc.)
4. Location (where therapy can occur)
5. Gifts
6. Self-disclosure
7. Referrals (when made and how they are made)

Question 8

Examples of Boundary Violations

Answer 8

• The health professional brings up his/her personal problems (inappropriate self-disclosure)
• Sex is brought up out of context, and discussion of sex is emphasized in sessions. Sex may be put forward as the answer to the patient’s problems.
• Sessions are booked at odd hours or when there are no other staff in the office.
• The professional presents him/herself as the expert who has answers to every problem.
• The patient is urged to become dependent on the professional and to separate herself from family and close friends.
• The patient’s assertive behaviour is criticized.
• Touching, such as hand holding and hugging, is presented as a necessary
  or even central part of the treatment.
• Alcohol or drugs, for use of the patient and professional, are made available during office visits.
• Major/significant gifts are given to the patient.
• Personal letters are written to the patient (unless part of therapeutic modality); unnecessary phone calls are made to the patient.
• Fees are waived for treatment sessions when unnecessary.
• The patient is directed to alter his/her physical appearance or dress to become more sexually attractive.
• The patient is not getting help for the problem that took her to the professional in the first place.
• The relationship feels uncomfortable, ambiguous, or confusing to the patient.
• With survivors of sexual abuse, the professional seems to be titillated by details of the abuse

Question 9

Dual/Multiple relationship definition

Answer 9

When a therapist has a second (or more) significantly different relationship with their client in addition to the traditional client-therapist bond

Question 10

AAMFT on Multiple Relationships

Answer 10

• “Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons.
• Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation.
• Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family.
• When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken.”

Question 11

CRPO on Multiple Relationships

Answer 11

• avoid dual relationships with current clients, except in extenuating circumstances, such as practising in a small community
• should avoid dual relationships with former clients
• apply and document the use of ethical and clinical judgment before engaging in dual relationships with current or former clients
• maintain professional boundaries, both online and in person

Question 12

Why boundary crossing and dual relationships is cautioned

Answer 12

there is potential for the therapist to misuse their power to influence and exploit clients for their own benefit and the client’s detriment

Question 13

Types of dual relationships

Answer 13

• Social (e.g. friends, neighbours, acquaintances)
• Professional
• Business (engage in business transaction with client - you buying something from them)
• Communal
• Institutional
• Forensic
• Supervisory (e.g. not both your supervisor and your therapist)
• Digital, online, or internet (e.g. friending or following on social media)

Question 14

potential disadvantages of socializing with current or former clients

Answer 14

• Therapist may not be as challenging as they need to be with clients they know socially because of a need to be liked and accepted by the client
• Therapists’ own needs may be enmeshed with those of their clients to the point that objectivity is lost
• Therapists are at greater risk of exploiting clients because of the power differential in the therapeutic relationship
• If you develop a friendship with a former client, then he or she is not eligible to use your professional services in the future

Question 15

Considerations for relationships with former clients

Answer 15

• The likelihood of harm to the former client
• Any power imbalance that remains
• Nature, length, and intensity of the former client-therapist relationship
• Nature of the emerging relationship
• Issues present by client in therapy
• Likelihood former client may want therapy in future
• Length of time since therapy ended
• Vulnerability of former client

Question 16

Steps to minimize risk in multiple relationships

Answer 16

• set healthy boundaries from the outset
• secure informed consent of clients
• discuss the potential risks and benefits
• consult with other professionals to resolve any dilemmas and seek supervision when needed
• document in clinical case notes
• examine your own motivations
• refer when necessary

Question 17

Considerations for having ‘guests’ in sessions

Answer 17

• setting clear boundaries by clarifying things such as: the number of sessions a guest may attend and having a referral plan in case the guest needs or asks for services themselves; how to handle communication with the guest outside of sessions (e.g., if the guest reaches out via email or phone)
• documenting why the guest is attending the session
• clarifying the service provided and who the client is (e.g., if the guest is a romantic partner or spouse, be clear the session is not couple therapy)
• defining the role and expectations of the guest during the session
• considering what to do if the guest requests a copy of the records for that session
• ensuring informed consent discussions clarify all of the above and the discussions are clearly documented.
• ensuring it aligns with the client’s goals - will help the client

Question 18

Harmful consequences for client of sexual contact with therapist

Answer 18

• distrust of the opposite sex
• distrust of therapists and the therapeutic process
• guilt
• depression
• anger
• feeling of rejection
• low self-esteem
• suicidal ideation

Question 19

How to respond to sexual attraction to clients

Answer 19

1. Learn: educate yourself on the possible adverse consequences for clients and therapists who engage in sexual activity
2. Recognize: identify sexual attractions and how to deal with these feelings constructively and therapeutically
3. Examine & Monitor: ongoing awareness of feelings and behaviours toward clients
4. Establish & Maintain: set and uphold clear boundaries when a client makes sexual advances toward you
5. Terminate: end the therapeutic relationship when sexual feelings obscure objectivity
6. Caution: Recognize that direct explicit disclosures of sexual feelings can run the risk of harming clients and may therefore be unethical.
7. Show Care: Maintain caring and warmth in the therapeutic relationship
8. Risk Management Approach: Avoid high-risk situations, e.g. consider timing of sessions, location, use of touch and self-disclosure and be more reserved
9. Consult/Get Care: Be willing to use supervision, consultation, and personal therapy in relation to these feelings and during your personal times of loss and crisis.

Question 20

CRPO definition of Undue Influence and Abuse

Answer 20

• No verbal, physical, psychological, emotional and sexual abuse of clients during and outside of therapy
• No above stated abuse to clients’ family, partners, representatives, or others that the client has a close personal relationship with
• Do not unduly influence clients (and above) with respect to personal life decisions, such as wills and powers of attorney

Question 21

Romantic/sexual relationships with current and former clients

Answer 21

Strictly prohibited with current clients, prohibited with former clients till 5 years after last session.
Considered sexual abuse and can lead to revocation of a member’s Certificate of Registration with the CRPO

Question 22

Consequences for the therapist of sexual abuse of clients/sexual relationship with client

Answer 22

• lawsuit
• convicted of a felony
• registration with college revoked or suspended
• being expelled from professional organizations
• losing their insurance coverage
• losing their jobs

Question 23

CRPO General Conduct Standard

Answer 23

Refrain from:
*illegal conduct relevant to suitability to practice
* knowingly practicing when impaired
*all conduct that having regard to all circumstances would reasonably be regarded by other RPs as “disgraceful, dishonourable, unprofessional, or unbecoming” by an RP
* misconduct beyond errors in judgment

Question 24

Rules for mandatory reporting of other RPs for misconduct

Answer 24

• Must report sexual abuse of client by another RP
• Must maintain confidentiality of client if it is sexual abuse
• consider impact on client
• Must document potential and actual reports
• Use judgement in deciding what to report
• Must have ”reasonable grounds”
• Cannot be “frivolous, vexatious, trivial or for ulterior purposes”; Made in good faith to protect vulnerable parties, general public

Question 25

Permitted means of revenue sharing

Answer 25

• with supervisor
• with agency/clinic
• with other RPs

Question 26

Exceptions to disclosing conflicts of interest to clients

Answer 26

• if it puts pressure on a client to behave in a certain way
• if disclosing breaches the confidentiality of the client or someone else
• if disclosing will be harmful to the client in some way

Question 27

Reasons bartering not advised

Answer 27

• hard to ensure equal pay/service
• creates dual roles/multiple relationships
• don’t know how it will be interpreted by the client (could be viewed as exploitation)

Question 28

Do boundaries change depending on client?

Answer 28

No, your boundaries must be the same for all clients (so no favouritism or preferential treatment). How your boundaries are expressed may vary based on the client and situation but you are consistent in this boundary crossing - would do same for all clients in same circumstance, it is not changing based on how much you like or dislike a client.

Question 29

Boundary Violation

Answer 29

Serious breach of a boundary that is unethical and causes harm to the client and is not acting in their best interest.

Question 30

Boundary Crossing

Answer 30

Departing from commonly accepted practice that may or may not help a client or harm a client, may be intentional or unintentional