CLINICAL VIGNETTE – A Phone Call from a Friend

Assignment – Vignette 2 – Ethics & Laws in Psychotherapy: Which clinical, ethical and/or legal issues are presented in the vignette? What provisions are made in the laws, board of psychology rules, and APA ethics code for responding to issues raised in the vignette? What do the authors of the assigned texts have to say? What is your personal position? How does your response to the vignette reflect your own cultural group values? How are your views informed by the assigned reading for the unit. If your values conflict with laws, psychology board rules, APA Ethical Principles or client request/values, state the conflicts and how you might resolve them?

Ethics Vignette

In this ethics vignette, the American Psychological Association’s (APA) Ethical Standards 3.05 and 3.06, concerning Multiple Relationships and Conflict of Interest, are primarily discussed in terms of resolving ethical and moral dilemmas that arise when a psychologist receives a phone call from an old friend seeking not only friendly support, but also professional guidance regarding his current psychoemotional and financial stress. This case was particularly interesting to me because I have occasionally found myself in similar situations for a variety of reasons. If a family member, for example, needs help, it is simple and convenient for them to approach me and ask for my advice or assistance. Another circumstance relates to that I served in the military for a few years and worked in war zones such as Afghanistan or post-war zones such as Kosovo. As a result, several of my friends who remained in the military have approached me several times for help, as they trust me and believe I understand what they have been through.

Previously, since I had not received extensive training in ethics and morality during my training as a therapist, I had to rely on my own common sense and notion of what was right or wrong in a given situation, as well as seek supervision when a case was particularly complicated. As a result, my desire to help led me to overextend myself and blur my personal and professional boundaries. Although my intention was to help my friends and family members in accordance with Principle A of the Ethics Code, which states that psychologists should “strive to benefit those with whom they work and take care to do no harm,” (APA, 2017, p. 3) as well as to protect their clients’ well-being and rights, in retrospect, rather than actually assisting them in becoming more independent and self-sufficient, I most often only contributed to temporarily alleviating some pain while also unconsciously trying to satisfy my own desire to help. Today, after several years of working as a therapist, I’ve become more aware of some of my own hidden patterns, which can manifest as unhealthy transference and counter transference issues or unprofessional behavior in my client relationship. With this in mind, and with the objective of better understanding the dynamics of future potential situations as a psychologist, I enjoy delving deeper into this specific case to gain a better understanding of the situation’s various facets. For structural purposes, this vignette is divided into four sections: a case illustration, ethical dilemmas, decision-making factors, and decision options.

Case Illustration – A Phone Call from a Friend

The following is the case illustration for the clinical vignette chosen for this assignment: Dr. Goodfriend receives a call from Buddy, his very close high school friend. Dr. Goodfriend speaks with Buddy about once every six to nine months. During those calls, the conversations typically focus on careers, family members, and the whereabouts about other classmates.

Buddy phoned Dr. Goodfriend in an apparent emotional anguish by the tone of his voice.  Buddy states that he has been feeling “stressed” over the last month. He explains that he recently lost his job and has been worrying about the financial impact that this is having on his family. Buddy adds that he has had trouble sleeping, has stopped exercising, has little energy, and fleeting thoughts of hurting himself. Buddy also shares that he has been short tempered with his wife and kids.

During the 90-minute call, Dr. Goodfriend tries to be a good listener, empathizes with Buddy’s difficult situation, offers advice on ways that Buddy can better manage his stress, provides him with general encouragement, and suggests a book that outlines stress management and anxiety reduction strategies.

At the end of the call, Buddy tells Dr. Goodfriend that he is feeling much better. Just as he is about to hang up, Buddy says, “Thanks. My wife told me that I should see a therapist but I told her that I could talk with you and that it would be much cheaper.” Dr. Goodfriend is unclear whether Buddy is serious or joking.

Questions to address: If you were Dr. Goodfriend, how do you feel about the phone call? Does Dr. Goodfriend need to phone his high school friend to clarify his last comment? Does Dr. Goodfriend need to encourage Buddy to become involved in therapy if symptoms persist? Should Dr. Goodfriend call Buddy and offer a few referrals? What factors influence this decision?

Ethical Dilemmas

Before we examine the APA’s Ethical Principles and Code of Conduct for Psychologists (Ethics Code) guidelines on Multiple Relationships and Conflict of Interest, let us briefly discuss the human side of this. From the psychologist’s perspective, the difficulty, in this case, is juggling multiple roles, such as being supportive to the friend without crossing the line into acting as his therapist, while also maintaining his own sense of boundaries and avoiding feeling exploited. Combining different types of relationships, each with their own set of complex variables, can create complications for both the therapist and the friend. As APA Ethics Director Stephen Behnke, PhD, JD, explains, “In the end, trying to blend your therapy role and relationships with friends and family members may place both your friendships and your psychotherapeutic work at risk” (DeAngelis, 2009, para. 7).

Three ethical dilemmas are illustrated by the dynamics of this vignette. The first ethical dilemma arises because the psychologist is not only a friend, but also a licensed psychologist with moral and ethical responsibilities toward clients, as well as friends and family. The psychologist’s second ethical consideration is as a friend and private individual with values and morals regarding how to behave appropriately as a supportive friend. Finally, the third ethical dilemma examines how he treats himself and respects his own boundaries, regardless of whether he is a psychologist or a friend, in order to avoid overextending himself and being exploited, which may have consequences not only for his own emotional well-being but also for how he may behave toward his friends in future encounters.

Decision-Making Factors

While the first ethical dilemma relating to multiple relationships is the most concerning from an ethical standpoint as a psychologist, the other two dilemmas are considered more personal and will therefore be discussed in greater detail in the section on decision options. Thus, in response to the first ethical dilemma, Ethical Standard 3.05a of the Ethics Code describes that a psychologist is in a multiple relationship when he “is in a professional role with a person and at the same time is in another role with the same person” (APA, 2017, p. 6). The primary concern with a multiple relationship, which is also described in Ethical Standard 3.06, regarding Conflict of Interest, is whether the professional role taken on by the psychologist “could reasonably be expected to impair the psychologist’s 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” (APA, 2017, p. 6).

While the psychologist in this vignette does not have a professional relationship with his friend, he is still providing advice and guidance in the role as a psychologist, which makes the preceding standard relevant, but, in my opinion, introduces some gray areas in its application. Another key distinction is that such relationships are not considered unethical if there is no reasonably foreseeable risk of causing impairment, exploitation, or harm to the person with whom the relationship exists. This brings us to the next gray area of this vignette: does the psychologist risk causing his friend any potential harm, both short and long term, by advising him?

Before attempting to answer this question, let us first examine some similar situations and additional information concerning dual relationships that, while not entirely applicable to this vignette, may provide insight into the issues raised in this vignette. To begin, Bersoff (2008) describes a situation similar to this one in which a professor teaches a course that an old friend wishes to enroll in. While it is not always possible, Bersoff suggests that the simplest solution is to avoid such situations entirely. Additionally, and largely consistent with this recommendation, a survey by Borys and Pope (1989) of 4,800 psychologists, psychiatrists, and social workers regarding their attitudes and practices regarding dual relationships revealed that the majority of respondents believed that dual role behaviors are unethical in the majority of circumstances.

However, as an illustration of the lack of consensus in this question concerning dual relationships, 21,4 percent responded that it was ethical under most circumstances and 4,2 percent that it was always ethical. It is possible that some of the 25% of respondents to Borys and Pope’s survey who believe it is ethical to enter a dual relationship live and work in environments that make this more likely. For instance, dual relationships are more prevalent in small communities and rural areas, where there are fewer people and thus a greater likelihood of psychologists inherently filling multiple roles within the community, such as parent, friend, and football coach. Gonyea et al. (2014) make a critical distinction in their research on how rural residents navigate dual relationships, specifically the type of relationship and degree of closeness between the therapist and client. For example, ”the degree of interaction outside of therapy,” “if I do not have an intimate relationship with them I will see them,” and “if I know we will socialize I will refer” were all influential factors (p. 131). The study concluded that when a relationship is deemed to be close, as is the case with personal relationships, this acts as a barrier to establishing a proper therapeutic relationship successfully. More specifically, closeness or kinship can refer to friends, family members, and their acquaintances; it can also refer to someone with whom one socializes or shares a common interest; and it can also refer to someone with whom one’s children play. However, if the dual relationship is viewed as having a low level of intimacy, as professional relationships were in this study, it becomes more ethically viable. Under such circumstances, as Faulkner and Faulkner (1997) discovered while conducting research on how to manage multiple relationships in rural communities, concepts such as neutrality and boundary violations then become critical for the therapist to comprehend and adhere to.

Naturally, the Ethics Code makes no recommendations regarding the second and third ethical dilemmas, which are viewed through the lens of the psychologist. Rather than that, one must examine the psychologist’s personal ethics and values and then relate them to the potential conflicts that arise from dual roles, which we will discuss further in the following section.

Decision Options

In relation to the first ethical dilemma, and in accordance with Ethical Standards 3.05a, Multiple Relationships, and 3.06, Conflict of Interest, it is evident that the psychologist should avoid entering into a therapeutic relationship with his friend, which is not really the issue in this vignette, and should also limit his involvement in guiding his friend in the role of a psychologist.  One way to accomplish this is to inform his friends, which, if necessary, is probably a good habit to establish early on in relationships with friends or family, that he is strongly advised ethically not to act in the capacity of a psychologist in close relationships. This is due to the various complications that may arise as a result of him doing so, which one may explain further if necessary. Nonetheless, as a friend, he may explain that he is more than willing to listen and support, which brings us to the second and third ethical dilemma.

In terms of the second ethical consideration, the psychologist’s values and morals regarding friendship, he may feel naturally compelled to act appropriately as a supportive friend. While it may be natural for a therapist to respond to friends the same way that they would to a therapy client, it is critical to maintain a separation between work and personal life. One of the primary distinctions between therapeutic and friendship relationships is that the former is unidirectional, whereas the latter is naturally bidirectional. In contrast to a therapeutic relationship, most relationships involve people gradually opening up as the other person does. As friends, we share experiences and details about each other’s lives that we would not share with a client. Therefore, as mentioned earlier, the therapist may need to work hard to avoid taking on the role of therapist with their friends and family. Rather than that, as Faulkner and Faulkner (1997) suggest, therapists should make a conscious effort to remain neutral and establish healthy boundaries in close personal relationships when it comes to mental health and emotional well-being.

Nonetheless, there are a variety of ways to maintain neutrality and healthy boundaries on the one hand, while also being a supportive friend on the other. Sheila Woody, PhD, director of clinical education at the University of British Columbia, suggests that we don’t need to leave all of our clinical skills unused. Simply listening to our friends is a simple way to support them and help them “feel understood, cared about, and less alone, and that they are in a place where it is safe to think more deeply about their problem” (DeAngelis, 2009, para. 16). Woody adds that we are within acceptable boundaries as long as we express concern, compassion, and genuine interest. We cross the line, however, when we attempt to solve the problems of our friends. To stay on the ethically correct side of the line, Woody suggests recommending various outside resources, providing psychoeducation, and, in addition to referral to therapy, reminding people about self-care (DeAngelis, 2009).

Another distinction that has aided me personally in maintaining healthy boundaries with close friends and family members is to distinguish between short-term “kindness” and long-term “goodness.” While the term “kind” is defined as having “a sympathetic or helpful nature” or having the ability “to give pleasure or relief” (Merriam-Webster, n.d.-a), the term “good” is defined slightly differently as “something useful or beneficial,” “advancement of prosperity or well-being,” or even “something conforming to the moral order of the universe” (Merriam-Webster , n.d.-b). These definitions make it quite clear that when we are kind, we are more often only temporarily assisting someone by being helpful and, hopefully, providing them with pleasure or relief. For example, I might give my daughter candy or ice cream to make her happy in the moment, even though I know it would be “evil” to do so every time she asks for it. Being good, on the other hand, means that I love and care for my daughter so much, both in the short and long term, that I am willing to accept conflict and maintain healthy boundaries with her even when she is sad or even angry with me. When I’m feeling guilty or have a bad conscience, I remind myself that simply doing what she wants can actually be a little evil to her. In that sense, if a therapist discovers that they are having boundary crossing issues as a result of being too kind, it may be beneficial to reframe the word kind to mean evil, and instead become good. People I know who have experimented with this way of framing it have described feeling more respected by their friends, which coincidentally also relates to another definition of the term “good,” namely “deserving of respect” (Merriam-Webster , n.d.-b).

Finally, in order to avoid overextending themselves and being exploited, in relation to the third ethical dilemma, therapists must respect and be aware of their own boundaries. One way to achieve this is to be congruent and pay attention to one’s deeper emotions, which, in my experience, frequently convey vital information, such as when our boundaries have been crossed. At the end of this case, for example, the friend is reported as saying that his wife advised him to see a therapist, but he preferred to speak with his psychologist friend because it would be much cheaper. It’s natural for the psychologist to feel exploited and undervalued by his friend. In that sense, the friend is taking advantage of the psychologist by engaging in dual relationships with him, assuming the role of the psychologist’s client without having to pay for it. The following is one alternative for dealing with this situation. After the psychologist has tuned in to how he is feeling on a deeper level, he could call the friend and describe how he is feeling, and then let the friend respond. In my experience, simply explaining how one felt during or after an experience, without implying that they did something wrong or are a bad person, the receiver, in this case the friend, can better understand the psychologist’s perspective and thus better understand the consequences of his actions, which to some extent are most likely unintentional.

In regard to whether the psychologist need to encourage his friend to become involved in therapy if symptoms persist, I believe that it is important to respect the free will of people. With that said, I also think as a supporting friend that it is important to show that one cares and is ready to listen if needed. Since beginning therapy can be associated with a plethora of obstacles for many people, such as a person’s religious or cultural beliefs, or a negative therapy experience in the past, many people may be hesitant to seek professional help. Additionally, widespread misconceptions about “talking to a therapist” may have stigmatized the subject for some. As a result of the numerous hurdles, if the friend is receptive, I would suggest that one can elicit whether or not the friend is interested in therapy. Timing is obviously important, as is allowing the friend to “walk through the door” on his own. After nearly two decades in a helping profession, I am convinced that if a person is not ready or willing to change, they will not. Trying to force someone to change is doing everyone a disservice. Instead, I advocate cultivating a sense of trust in life and in the process, in accordance with the old saying that “when the student is ready, the master appears,” which in this case may translate to “when the client is ready, he seeks out a therapist he is willing to pay for.”

References

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). http://www.apa.org/ethics/code/index.html

Bersoff, D. N. (2008). Ethical conflicts in psychology (4th ed.). American Psychological Association.

Borys, D. S., & Pope, K. S. (1989). Dual relationships between therapist and client: A national study of psychologists, psychiatrists, and social workers. Professional Psychology: Research and Practice, 20(5), 283-293. http://dx.doi.org.tcsedsystem.idm.oclc.org/10.1037/0735-7028.20.5.283

DeAngelis, T. (2009, November). Boundary watch: Now that you’re gaining clinical expertise, are your friends clamoring for free professional advice? Here’s how to respond. gradPSYCH. Retrieved March 3, 2022, from https://www.apa.org/monitor/jan03/10ways

Faulkner, K. K., & Faulkner, T. A. (1997). Managing multiple relationships in rural communities: Neutrality and boundary violations. Clinical Psychology, 4(3), 225–234. https://doi.org/10.1111/j.1468-2850.1997.tb00111.x

Gonyea, J. L., Wright, D. W., & Earl-Kulkosky, T. (2014). Navigating dual relationships in rural communities. Journal of Marital and Family Therapy, 40(1), 125–136. https://doi.org/10.1111/j.1752-0606.2012.00335.x

Merriam-Webster. (n.d.-a). Kind. In Merriam-Webster.com dictionary. From https://www.merriam-webster.com/dictionary/kind

Merriam-Webster. (n.d.-b). Good. In Merriam-Webster.com dictionary. From https://www.merriam-webster.com/dictionary/good