ETHICS AND PROFESSIONAL ISSUES PRESENTATION- FINAL.pptx

ETHICS PRESENTATION

1. Attraction, Romance, and Sexual Intimacies With Clients and Subordinates GROUP MEMBERS: NASHWA MEKAN IQRA NAZ HIBA HASSAN MINTO

2. Sexual Attraction Therapists Attracted to Clients – Nashwa Mekan Over the course of one’s career, the therapist will more than likely face erotized stirrings in the context of their professional relationships with at least one client. Unexpected, intense, or reciprocated attraction can blindside and befuddle any therapist, no matter how competent or well trained (Pope, 2013). Fleeting erotic feelings toward others are part of human nature; how we manage such feelings lies at the heart of ethical professionalism. Of the 95% of the male therapists and 76% of the female therapists admitting feeling attracted to at least one client, the majority felt guilty, anxious, or confused. Despite the high rates of attraction, only 9.4% of the men and 2.5% of women allowed attraction to escalate it sexual liaisons with their clients.

3. To whom are therapists attracted to? Physical attractiveness to the client Positive mental/cognitive traits (when client is intelligent, well educated or articulate. Vulnerability attributes (the client is needy, childlike, sensitive and fragile). Client has good personality. Client who fulfilled the therapist’s needs (boosted the therapist’s image, alleviated the therapist’s loneliness or pressures of home). Client seemed attracted to therapist or reminded them of someone else. A very small percentage of therapist admitted of being attracted to clients with serious psychopathology.

4. CASE A young Asian client saw herself as homely and unlikable. Letme Fixit, Ph.D., explained how he was only trying to boost her self-esteem when he told her she had beautiful eyes and how he could imagine her having a close relationship with a “white man” like him, even though it could not be him as much as he would like that. His attempts to exonerate himself on the grounds that he went overboard trying to convince the client that she was attractive were not persuasive to a licensing board.

5. This case illustrate how overt expressions of attraction, even if they are not actually felt, can be problematic. DR. Fixit may have well meant in his own mind, however his actions were insensitive and had a culture bias. He focused on physical attributes of the client and also clearly asserted white supremacy.

6. CASE Supervisee Jack Captivated’s new client was a sweet breath of fresh air. He struggled to keep from offering advice that clearly revealed his own desires. When she expressed ambivalence about moving away to be with her boyfriend, he advised such a move would not serve her well. He admitted the conflict regarding his feelings to himself but did not know how to resolve it. He was afraid to approach his supervisor because he feared that she would likely place negative comments into his record.

7. Ideally, supervisors form alliances early on that encourage their supervisees to self-reflect and openly discuss their feelings. Competent supervisors strive to help trainees address all manner of ethical challenges. Jack knows he has stumbled, so the time is right to ask for supervisory help, although handling sexual feelings is most uncomfortable supervision topic. If therapist is unable to bring their feelings under control and the attraction is compromising working with the client. It is suggested a sensitive termination and referral as a way to protect both parties.

8. Clients attracted to Therapists Clients sometimes become sexually attracted to, and direct sexualized behaviors toward, their therapists, such as suggestive looks or teasing ( Sonne & Jochai . 2014 ), which come as no surprise, given the intimate nature of psychotherapy. When a client directly expresses erotic feelings , it is important to preserve professional boundaries and protect the client’s self-esteem, because it can be humiliating to client who has disclosed their innermost feelings. Therapists must remember that when a client discloses erotic feelings toward the therapist, it does not necessarily mean that the client expects them to be acted on . What the therapist interprets as seductive behavior could be signs of dependency (Gregory & Gilbert, 1992). The better course of action is further exploration of the client’s feelings and putting the focus back on why the client is in therapy.

9. Therapist internal processing to client’s attraction Three components according to Hartl , Zeiss, Marino, Regev , and Leontis (2007 ). How does the therapist interpret the meaning of the client’s behavior? Was it intentional ? Was it perhaps an attempt to control, seduce, or dominate ? If it seemed to be unintentional , was the client trying to affiliate or bond? 2. How does the therapist view his or her part in bringing this on? What role did he or she play that may have elicited this behavior ? Might a joke or offhanded comment have prompted inappropriate behavior? 3. What was the therapist’s own internal emotional response? Did it feel flattering , bewildering, annoying, or disgusting?

10. If client becomes aggressively seductive : Gutheil and Gabbard (1992) suggested telling the client that therapy is a “talking relationship” and discussing why the behavior is inappropriate . They suggested saying something like this: There are many people who are available to sleep with you, I’m trying to make a different contribution to your life. I’d like to be your therapist and what you’re asking is not what a therapist does,” or, “This room is meant to be a safe space for you to learn what it’s like to have a caring relationship without sex, so that you can confront the problems for which you came to get help ”. Rarely, a patient’s acting out of exceptionally strong sexual or romantic interests may be uncontainable. In such circumstances , the best course of action is to refer the client to another therapist.

11. CASE Dr. Howes worked with a woman who started complimenting him in almost every session. Instead of discussing her marital problems, she wanted to focus on her ideal future. This included an ideal husband whose qualities resembled the compliments she was giving Dr. Howes . When he brought this up, she admitted imagining a life with him.

12. Dr. Howes then talked about how her fantasy of a caring, emotional, and non-judgmental relationship with me was a welcome departure from the reality of her marriage, which was complicated, dry, and difficult. When she realized her fantasy was an escape with no future, the client refocused on her marriage. The therapist in this case handled the situation with supportive and non-judgmental guidance.

13. CASE Edie Persistent’s therapy with Tyler Engulfed, Ph.D., proceeded without incident at first . But soon, Ms. Persistent became belligerent, demanding that Dr. Engulfed allow her to sit on his lap during the entire therapy hour. She ailed about uncontrollably whenever Engulfed attempted to get her back into a chair. The demands accelerated and became more bizarre, including wanting him to watch her masturbate and have sex with her to simulate a rape she endured as a child.

14. Physically Touching Clients Touch as a mode of communication can convey: Support, Consolatio n Empathy, Caring, Sincere concern. Touch can also signal: Sexuality, Elicit anxiety, Fear, Aggression.

15. Kinds of Touching Non-erotic Touching Erotic Touching Kissing, Romancing and Casually Dating Clients

16. Non-erotic Touching Touch in psychotherapy is the most controversial of all boundary crossings, largely because it can be associated with sex which can provoke anxiety and confusion (Westland, 2011). When therapists do touch clients, the circumstances should be considered appropriate like is it expressions of emotional support and reassurance or is the touch during initial greeting or closing of sessions. Very brief non-erotic touching on the hand, back, and shoulders involves the safest areas of touch and can still convey a compassionate, supportive message (Wilson, 1982). Stenzel and Rupert (2004) found that 90% of their national survey sample of therapists never or only rarely touched clients, most often to shake hands on entering or exiting a session. Clients may initiate touching because of a desire to be physically close to their therapist, and its then a therapist’s decision to touch or not touch must often be made quickly.

17. C ASE Janet Demure complained to an ethics committee that her therapist, Patten Strokem , Psy.D ., behaved in a sexually provocative manner , which caused her considerable stress and embarrassment. He allegedly put his arm around her often, massaged her back and shoulders, and leered at her. Dr. Strokem was shocked on learning of the charges and vehemently denied any improper intentions. He claimed he often put his hand briefly on his clients’ backs and patted or moved his hand with the intention of communicating warmth and acceptance. His customary constant eye contact was his way to communicate that clients had his full attention. He admitted that Demure seemed uneasy but expected this would quickly pass as it did with others who were not used to such expressions of caring.

18. Dr. Stroke’s humanistic approach disposed him to considerable nonerotic touching of clients. Regardless of therapeutic orientation, however, it is necessary to remain aware of individual clients and their special needs, issues, and a sensitivity that may well require a different demeanor. Cultural factors regarding touching traditions and tolerances must also be taken into consideration.

19. Erotic Touching When therapists intentionally touch clients with erotic intent , a boundary violation has occurred. Behavior primarily intended to arouse or satisfy sexual desires is the general definition of erotic contact offered by Holroyd and Brodsky (1977, 1980). Touching any part of the body is unethical if the purpose is self-gratification .

20. CASE Hands Solo, L.M.H.C., had his license to practice suspended when two clients came forward complaining about his belligerent physical advances. Although Dr. Solo never proposed having a sexual relationship with either woman, he would pull them in close to his body and rub against them on their arrival for sessions. Both clients directly expressed discomfort, but he only winked and ignored their complaints.

21. Kissing, Romancing and Casually Dating Clients Most ethics cases involving sexual misconduct started with seemingly harmless compliments before advancing to such acts as gift giving, going out for coffee, a kiss on the cheek, moving the client’s appointment to the last one of the day, and proceeding from there. Courtship-style behaviors are not classified as “sexual intimacies ,” casual social excursions outside the office become risky because they typically involve personal self-disclosure and other behaviors leading to misunderstandings or confusion in clients, even with no therapist motivations beyond platonic pleasantries (Simon, 1991).

22. CASE Willy Inchworm, Ph.D., was attracted to Selma Receptive, his client of several months. Selma readily accepted what Dr. Inchworm believed, at the time, to be a professionally appropriate invitation to attend a lecture on eating disorders, given that Selma’s sister had a history of anorexia nervosa. The lecture concluded at 5 p.m., so Dr. Inchworm invited Ms. Receptive to stop for a bite at a nearby bistro. The next week, Inchworm accepted Receptive’s gift of a book written by the speaker from the previous week. The following week, Inchworm agreed to a reciprocal dinner at Receptive’s apartment. Afterward, as they enjoyed a third glass of wine, they looked into each other’s eyes, embraced, kissed for a while, and retreated into the bedroom.

23. American Psychological Association ( APA) The American Psychological Association (APA) did not adopt a prohibition against sexual intimacies with clients until 1977. Today, all major mental health professional codes have clear prohibitions against engaging in sexual behavior with current clients. APA: 10.05; American Association for Marriage and Family Therapy [AAMFT]: 1.4: Sexual Intimacy with current clients or with known members of client’s family system is prohibited. American Counseling Association [ACA]: A.5.a: Sexual or romantic counselor client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. The prohibition applies to both in-person and electronic interactions or relationship.

24. American Psychological Association (APA) National Association of Social Workers [NASW] 1.09 ): social workers under no circumstances engage in sexual activates, inappropriate sexual communication through the use of technology or in person, or sexual contact with current clients, whether such act is consensual or forced. Social workers should not engage in sexual activities contact with clients relatives or individuals with whom the client maintains close relationships with.

25. CASE Hap Bowlover , Ph.D., wrote a letter in response to an ethics committee inquiry insisting he was worn down by a client who “showed up wearing dresses with the neckline and the hem- line almost meeting and started flirting with me the minute she walked into my office .” He was convinced that she set a trap for him.

26. Harm to the Clients Pope (1989a, 1994) described a cluster of symptoms seen in some clients who endured sexual relationships with their therapists . Ambivalence about the therapist, Feelings of guilt, as if the client were to blame for what happened, F eelings of isolation and emptiness, Cognitive dysfunction, particularly in the areas of attention and con- centration; Identity and boundary disturbances; difficulties in trusting others as well as themselves, Confusion about their sexuality , Liability of mood and feeling out of control,

27. Harm to the Clients Suppressed rage, Increased risk for suicide or other self-destructive reactions. Clients express outrage over what was done to them, Damaged or destroyed relationships in their lives, Suffered feelings of abandonment, exploitation, and hopelessness, Clients questioned whether they could possibly trust another therapist again, Clients often admitted pressing charges to help ensure that the therapists would not harm anyone else.

28. He Said, She Said The False Allegation IQRA NAZ RISKS TO THERAPISTS WHO ENGAGE IN SEXUAL BEHAVIOR WITH CLIENTS

29. He Said, She Said. Sexual transgressions with clients appear to be the most frequent specific cause for disciplinary action Some might think those who engage in sexual intimacies with clients are risking very little because sessions are conducted in the absence of witnesses. If a client complains, the accusation can be denied. Therapists may cite “fantasy ,” “ delusion,” or “transference” as the basis for the charges. Does this work? Sometimes it does. Not all sexual intimacy cases are decided definitively because neither party’s story can be substantiated by a preponderance of evidence. But, damaging fallout occurs anyway because others often know of the charges, including confidants, spouses, and employers. When a violation cannot be sustained, the therapists are not fully exonerated by default. Cases closed on account of lack of evidence about a single complaint may be reopened if a subsequent charge against the same individual suggests a pattern of offending.

30. Other resources include the availability of expert witnesses, subsequent therapists who are prepared to testify regarding the damage caused by previous sexual activity with previous therapists, and clinics specializing in treating sexual abuse by mental health professionals . If a guilty verdict is reached in court, therapist/ defendants may ultimately bear the total cost of any damages, and these can be substantial . Modern technology has been brought to bear in these cases. An undercover agent wore a radio transmitter to substantiate how a psychologist sexually preyed on his attractive female clients . Numerous technological options for clients to prove guilt include saved e-mails, text messages, and information recorded on other devices, not always with the offender’s awareness .

31. Case Little did Sam Snore, M.A, know until hearing from an ethics committee that his now ex-client, Annie Quick pic, photographed him lying nude on a motel bed. His explanation that the photos must have been stolen from his office desk drawer by a now-vengeful client was not persuasive.

32. False Allegation It is difficult to acknowledge that anyone would unjustly risk destroying someone’s professional and personal life with a false accusation, but it has occurred in an estimated small percentage of cases Before engaging in any form of non-erotic touching or paying a compliment that could be interpreted as flirtatious or suggestive, it is highly recommend making certain you thoroughly understand your client’s psychological functioning and history. Some clients may remain unsuited to such comments or any form of touching for the duration of therapy. Thus, any act that could conceivably be misconstrued at some later point should be entered into the client’s file (e.g., “sent flowers for husband’s funeral,”) T herapists are advised to document incidents involving clients’ sexually laden or intense personal interest as well as the response. competence, sensitivity, and a habit of regularly monitoring every client’s treatment needs as well as remaining fully self-aware will preclude problems from erupting and still allow numerous avenues for expressing caring and compassion.

33. SEXUAL RELATIONSHIPS WITH FORMER CLIENTS The Uneasy R ules The Case for Perpetuity

34. The Uneasy Rule In 1992- the APA ethics code revision team proposed a lifetime ban on sex with previous therapy clients based on the risks to clients, practitioners, and the profession (Vasquez , 1991 ). After lengthy debates, the APA arrived at a clumsy compromise. A 2-year post-termination moratorium clause placed clear limitations in the short run but opened the opportunity for sexual relations without professional repercussion after 2 years. The 1992 APA code also defined as unethical any statements or actions on the part of the therapist while therapy was active that suggested or invited the possibility of an eventual relationship with a client.

35. The 1992 APA code also listed considerations to be weighed before embarking on a sexual relationship with an ex-client, this included, Time passage since termination (the longer the delay, lower the ethical risk) C lient’s current mental status and degree of autonomy T ype of therapy, how termination was handled W hat risks may still present themselves should a sexual relationship commence. Currently, the American Psychiatric Association (1992, 2013) and AAMFT are the only organizations to place a total ban, with no exceptions no matter how extraordinary.

36. The Case for Perpetuity Data suggest well over half of the post-termination sexual liaisons between therapists and their clients began quickly, within the first 6 months ( Gartrell et al., 1986 ). The primary concern is that placing a time stamp for post-termination sex may alter the therapy relationship from the onset by establishing the “silent” dual role of therapist and potential lover . A therapist’s responsibilities do not conclude at termination. Clients may want to reenter therapy at some point. Client rights to privacy, confidentiality , and privilege remain unaffected. The possibility of a subpoena of records and resulting court appearances also exists. As a result, clients could be severely disadvantaged should they have need of professional services from a therapist who was also a lover (or ex-lover), especially if the subsequent sexual liaison ended badly.

37. Case Donald Reprisal, D.S.W., and his ex-client Alka Hollick were married two and a half years after therapy was terminated. They had a child the next year and divorced a year later . During a bitter custody battle, Dr. Reprisal brought up his wife’s previous alcohol abuse and other issues raised in therapy.

38. DELIVERING PSYCHOTHERAPY TO FORMER SEX PARTNERS E ntering into therapy relationships with former lovers is unethical. Such a prohibition reflects common sense given the probable inability to remain objective. A sexually intimate past is not a foundation on which to build an effective therapeutic alliance. The therapist can assist by offering an appropriate referral. Both parties come with emotional baggage . The following case explains this, Sonja Ex, L.M.F.T., agreed to work with Dennis Didit as a client, even though 5 years previously they had an intense romantic relationship lasting several months. Despite Ms. Ex’s disclosure that she was now happily married with two children, Didit started recalling lustful moments from their past and began making suggestive remarks. After four sessions, Ms. Ex terminated therapy with Didit because, as she told him, “You are not taking therapy seriously.” Didit wrote to an ethics committee, stating , “Ms. Ex took me for $400 before tossing me out as revenge for having dumped her 5 years ago.”

39. SEXUAL RELATIONSHIPS WITH CLIENTS’ SIGNIFICANT OTHERS T he ethics codes of professional associations disallow entering into sexual relationships with such persons and forbid terminating the active client as a way of circumventing compliance. The following case explains, Wadyo Wannado , Ph.D., a clinical child psychologist, treated Bobby Boyster as an outpatient . Bobby, age 7, was showing signs of an adjustment disorder in reaction to his parents’ deteriorating marriage. Dr. Wannado saw Bobby alone on a weekly basis for several months and met jointly and individually with his parents on three or four occasions. Soon after Bobby’s therapy was terminated, the relationship with Bobby’s mother became sexually intimate. The father filed an ethics complaint against Dr. Wannado , who claimed no wrongdoing because he was no longer seeing Bobby, and the mother was never a client

40. PREVENTION, EDUCATION, AND DEALING WITH OFFENDERS- HIBA MINTO Educating the Public: In the late 1980s, the Committee on Women in Psychology issued a brochure, “If Sex Enters Into the Psychotherapy Relationship” (1989 ), Offering specific advice about what to do should clients be exploited. Educational materials appear to successfully enlighten consumers about inappropriate therapist behaviors. Therapists include in their descriptions of how they work that therapy will be free from any sexual harassment or activity.

41. Educating Students in Training and Already-Practicing Therapists: Continuing education courses for already-practicing therapists. Supervisees must feel comfortable disclosing their feelings of attraction frankly with supervisors. Supervisory discomfort with sexual feelings leads to the subtle and unfortunate communication that such matters are not to be discussed.

42. Rehabilitation, Sanctions, and Criminalization Intervention programs present a dilemma given that a substantial proportion of sexually exploitative therapists move on to take advantage of multiple victims. Rehabilitation potential is likely related to the type of offender. Appropriate disciplinary actions are best decided on a case-by-case basis, and some offenders may be safely returned to practice while others may not. The APA Ethics Committee sometimes recommends supervision or referral for therapy among the sanctions sexual offenders receive. The penalty often includes expulsion from the APA or a forced resignation, stipulating conditions for reinstatement ( usually after 5 years) if the psychologist can offer evidence of rehabilitation.

43. CASES Case 9–42: A Michigan psychologist was convicted on three counts of fourth-degree criminal assault for having sex with a teenage client. He will serve 60 days in jail, receive 5 years of probation, and be listed as a sexual offender for 25 years ( Genellie , 2011). Case 9–43: An Ottawa psychiatrist convicted of repeatedly sexually assaulting a male patient received a 2-year prison sentence. The sentence was upgraded due to the “manifestly inadequate” original sentence of 2 years of house arrest given “ the extreme nature of the breach of trust” ( Canadian Press , 2010).

44. TREATING SEXUAL EXPLOITATION BY FORMER THERAPISTS Even though exploited clients recognize the need for counseling, they often do not trust their own ability to make wise decisions and may even fear revictimization . Practicing therapists’ chances of encountering at least one client claiming abuse by a previous therapist are estimated to be about 50 %. Treating such clients presents a unique set of subsequent treatment challenges, including the probable need to address whatever brought the client into psychotherapy in the first place.

45. CASE Case 9–48: Mary Wary, a fragile and highly anxious woman, sought therapy with Kantbe So, Ph.D ., claiming her previous therapist fondled her breasts and tried to have intercourse with her. The accused therapist, well regarded in the community and active in the local psychological association, seemed pleasant and happily married.

46. SEXUAL RELATIONSHIPS WITH STUDENTS AND SUPERVISEES Given the trappings of most educational environments, some students and some professors will confront the temptation to enter into romantic relationships based on motivations running the gambit from gaining some future advantage to consummating true love. Data from anonymous surveys revealed that sexual contact between clinical supervisees and supervisors occurs fairly frequently.

47. CASE Case 9–49: Cloris Push, Psy.D ., made numerous suggestive remarks to her student, Stan Shun, implying the closer their personal relationship, the more likely Shun’s successful completion of his degree program . Shun was not particularly attracted to Professor Push, but he believed that rejecting her advances would endanger his academic status.

48. Risks to Students and Supervisees When the affairs of students and their educators go askew, the effects must be reckoned with in both the private and professional realms. Emotional fallout can include grief, embarrassment, fear, bitterness, and a desire for vengeance . Educators are actually more vulnerable than therapists in several ways . Students have ready access to each other , unlike psychotherapist’s clients, leaving the serial exploitative educator open to coalitions of accusers and with a greater probability for exposure . Also, students do not have to deal with off-campus licensing boards or ethics committees .

49. CASE Case 9–50: After an affair between Gary Goferit , Ph.D ., and Paula Jettison had ended, Jettison filed charges against Goferit for sexual harassment and exploitation . She also contacted the local newspapers. She was joined by several other students, who claimed they, also, had experienced the same abuse by Goferit . Dr. Goferit lost his job and his wife.

50. WHAT TO DO • Strive to remain self-aware when it comes to your feelings about clients, especially feelings of sexual attraction. • Maintain professional contacts with whom to consult about boundary crossings and violations . • As an educator or supervisor, ensure supervisees have adequate training in and freedom to discuss sexual feelings and relationships with regard to their clients. • When tempted to disclose a personal feeling or touch a client, ask yourself, “How will this help the client?”

51. WHAT TO WATCH FOR • Carefully evaluate clients and their vulnerabilities before engaging in any non-erotic touching. Some clients remain averse to touching. • Be wary of entering into a sexual relationship with former clients, even if the moratorium period as mandated by your ethics code has passed . • If you are facing crises, regrets, or emotional pain , realize that you may be at risk for inappropriate boundary violations. • Avoid as much as possible seeing clients in social situations that could be viewed or misunderstood as dating or courtship behaviors.

52. WHAT NOT TO DO • Never engage in sexual intimacies with current clients . • Never engage in erotic touching or sexual activity with a current client or student over whom you have evaluation responsibilities. • The kindness, passivity, adoration, and vulnerability of clients must never be exploited for personal gratification. • Do not keep sexual feelings toward clients to yourself. Find someone appropriate with whom to consult. • Avoid practicing in isolation. • Never accept a past lover as a client. • Do not engage in sexual relationships with students over whom you hold (or may hold in the future) evaluative authority.