Verified by 
Alcoholism
Colleague asks: "Can I just send them away? Any risk management concerns?"
Thinking only about risk management can be a trap!
Posted December 7, 2010
Risk management or Positive Ethics or Both?
The other day, I received an email message from a colleague asking for my input on the following issue:
What if I am doing an intake with a new psychotherapy client and it became clear that the individual is intoxicated on alcohol or high on drugs? They are not interested in hospitalization. They’re not expressing suicidal or homicidal ideation, so I have no real cause to violate confidentiality and hospitalize them involuntarily. Can I just send them away? Any risk management concerns? I would discourage them from driving, but would not want to wait for them to sober up, especially if they become oppositional or belligerent. If they were already a client of mine I would reschedule and tell them to not get intoxicated prior to a session as it makes for less productive work. If not a returning client, can I just tell them I won’t see them and give them other resources? What are the risk management guidelines for handling a situation such as this, and for documenting it?
This therapist is clearly looking at the situation with a risk management lens—asking, “What do I need to do to limit risk and keep myself out of trouble?” Not a bad idea—staying out of trouble is a good thing. But thinking only in terms of risk management can be a trap. It leads therapists to focus on the minimum professional behavior that is necessary to steer clear of litigious activity (Handelsman, Knapp, & Gottlieb, 2009). In the short term, it keeps therapists focused on rules. Actions based on this lens might be based more on fear of lawsuits and complaints than on motivations to help clients improve.
In the long term, this rule-based mindset is likely to deter professionals from seeing the good work they do with clients and enjoying their work. Instead, they may see work as a place of dreading the difficult client because of the “what ifs”. “What if this client questions my approach with them? What if this client seeks a second opinion about our work together? What if I make a mistake and this client takes me to court? What if….” An exclusive use of this negative mindset could lead to poor and even detrimental work with clients (). A mind preoccupied by anxiety has little room for creativity and excellence.
I would encourage my colleague who sent the email to augment the risk-management/rule-and-fear-based lens with a consideration of this scenario from a positive ethics lens (Handelsman, Knapp, & Gottlieb, 2002; 2009). I would say, “Reach for the ethical ceiling” (Bersoff, 1994),
draw from professional and personal virtues such as compassion, integrity, and respect (Fowers (2005; Meara et al. 1996), remember your motivation to help people, and act on these virtues and motivations in conjunction with the ethical principles such as beneficence, nonmaleficence, and autonomy (Beauchamp & Childress, 2008; Kitchener & Anderson, 2010).
What might come of this positive approach? First, I would encourage my colleague to think of how she could help the client even if she chose not to accept the client in therapy. For example, she could try to keep the client from causing harm to himself and others. She might do a careful assessment to see if the client is so drunk or high on some drug that he is not safe to be operating a vehicle. This is a good idea from both the risk-management and positive approaches. In a more positive vein, however, the therapist could express respect and support for the client’s interest and good intention in seeking therapy and explore with the person a time when the two of them could reconnect to see if therapy might indeed be an option.
From a risk-management perspective, the therapist needs to judge whether the client’s inebriated state and determination to get home without assistance would constitute enough justification for the therapist to contact the police and try to alert them to a person who is driving under the influence. On a more positive note, the psychologist might brainstorm with the client how he could get home safely (Is there family, friend, cab, etc., he could contact for a safe ride home?). This might be a much better option than merely waiting for the client to sober up.
Another positive behavior that would not be necessary from a purely risk-management approach would be for the therapist to consider making a phone call to the client the following day. This call would be to check in on the client, once again express concern and respect, and perhaps provide a brief reminder of any upcoming meeting.
Rule-based and positive approaches are not mutually exclusive. Indeed, going beyond the minimum includes the minimum! But adding a positive approach to ethical deliberations can help therapists do good work, and do it for longer, because they are acting with energy that stems from their hearts in addition to their attorneys.
Beauchamp, T. L., & Childress, J. F. (2008). Principles of biomedical ethics (6th ed.). Oxford, England: Oxford University Press.
Bersoff, D. N. (1994). Explicit ambiguity: The 1992 ethics code as an Oxymoron. Professional Psychology: Research and Practice, 25, 382–387.
Beutler, L. E., Malik, M. L., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., et al. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 227–306). New York: Wiley.
Fowers, B. J. (2005). Virtue and psychology: Pursuing excellence in ordinary practices. Washington, DC: American Psychological Association.
Handelsman, M.M., Knapp, S., & Gottlieb, M.C. (2009). Positive ethics: Themes and variations. In C.R. Snyder & S.J. Lopez (Eds.), Oxford handbook of positive psychology (2nd ed., pp. 105-113). New York: Oxford University Press.
Kitchener, K.S. & Anderson, S.K. (in press). Foundations of Ethical Practice, Research, and Teaching in Psychology and Counseling, 2nd edition, New York: Routledge/Taylor & Francis Group
Meara, N. M., Schmidt, L. D., & Day, J. D. (1996). Principles and virtues: A foundation for ethical decisions, policies and character. The Counseling Psychologist, 24, 4–77.
Photos by lumaxart and justinbaeder
