Often the answer to the question posed
in the title of this article is obvious...but sometimes it isn’t. This
article will discuss the importance of defining who is a "client" or
"patient" in the context of the APA Ethics Code. The APA Ethics Code
and most state licensing acts share an assumption that the answer is
obvious. As in North Carolina, most state licensing acts construe the
practice of psychology broadly. For example, the Practice Act in North
Carolina states that "Psychological services may be rendered to individuals,
families, groups, and the public" [N.C.G.S. 90-270.2 (8)]. Further,
while the notion of who is a recipient of our services is defined very
broadly, N.C.G.S. 90-270.15(a)(11) allows for disciplinary action against
the license of a psychologist who "has practiced psychology in such
a manner as to endanger the welfare of clients or patients." I encourage
all Registrants to be familiar with how the practice of psychology is
defined in your state and who is considered a recipient of psychological
services.
The APA Ethics Code makes an implicit
distinction between clients or patients and other recipients of psychological
services. Standard 1, General Standards, of the Ethics Code states "These
General Standards are potentially applicable to the professional and
scientific activities of all psychologists." Standard 1.01, Applicability
of the Ethics Code, states that the Ethical Standards apply "...only
if the activity is part of his or her work-related functions or the
activity is psychological in nature. Personal activities having no
connection to or effect on psychological roles are not subject to the
Ethics Code." These standards are, therefore, not intended to apply
to our personal activities, but are intended to apply to ALL of our
work-related activities (not just when the recipient of our services
is a client or patient). It is not uncommon for psychologists to be
unclear about this issue. For example, the standards included in the
General Standards section such as 1.13, Personal Problems and Conflicts,
1.14, Avoiding Harm, 1.17, Multiple Relationships, of who is a recipient
of our services is defined very broadly, N.C.G.S. 90-270.15(a)(11) allows
for disciplinary action
against the license of a psychologist who "has practiced psychology
in such a manner as to endanger the welfare of clients or patients."
I encourage all Registrants to be familiar with how the practice of
psychology is defined in your state and who is considered a recipient
of psychological services. The APA Ethics Code makes an implicit distinction
between clients or patients and other recipients of psychological services.
Standard 1, General Standards, of the Ethics Code states "These General
Standards are potentially applicable to the professional and scientific
activities of all psychologists." Standard 1.01, Applicability of the
Ethics Code, states that the Ethical Standards apply "...only if the
activity is part of his or her work-related functions or the activity
is psychological in nature. Personal activities having no connection
to or effect on psychological roles are not subject to the Ethics Code."
These standards are, therefore, not intended to apply to our personal
activities, but are intended to apply to ALL of our work-related activities
(not just when the recipient of our services is a client or patient).
It is not uncommon for psychologists
to be unclear about this issue. For example, the standards included
in the General Standards section such as 1.13, Personal Problems and
Conflicts, 1.14, Avoiding Harm, 1.17, Multiple Relationships, and 1.25
Fees and Financial Arrangements, are not therapy standards. In fact,
most of the standards in the Ethics Code are intended to be broadly
applicable to the work-related activities of all psychologists and are
not limited to clinical or health service practice with clients or patients.
It is primarily in Section 4, Therapy, that the distinction between
therapy clients or patients and other recipients of our services needs
to be made by the psychologist in determining applicability to their
professional activities. I am aware of no definitive professional standard
of practice that establishes criteria for defining who a "client" or
"patient" is and whether the psychological service being rendered is
"therapy". Even for a psychologist offering traditional psychotherapy
services, it may not be clear at what point a member of the public becomes
a client. Is it at the time of an initial phone contact, the initial
session, the second session, the first payment of a fee? Particularly
in the area of family and couple treatments, the definitions may become
more blurred. Is a husband who joins his wife and her psychologist for
several joint sessions a patient? These latter questions touch quite
directly on differences in theoretical orientation. Significant professional
differences of opinion exist, for example, between psychologists who
view psychopathology as arising primarily out of dysfunction in interpersonal
interaction systems as contrasted with those who view psychopathology
as arising primarily out of individual psychological and/or biological
factors. The issue is further clouded by insurance reimbursement practices
that may not reimburse for "family therapy" but may for individual treatment
that includes collateral contacts with family members. The issue of
confidentiality and release of records can also become very complicated
when treating couples and families.
Psychologists also frequently provide consultative services to individuals who are not generally considered to be therapy clients or patients. It is clearly a psychological service to provide consultation to a teacher on classroom management skills or to a group of parents on child development issues. While we have responsibilities to all members of the public with whom we have professional contact, those defined as clients or patients are offered some special considerations and protections under Standard 4, Therapy.
What are some of these special protections?
Standard 4.01, Structuring the Relationship, describes a more detailed
process of defining the relationship than is found in the generally
applicable portions of the Ethics Code. Psychologists are also reminded
in Standard 4.01 to refer to Standard 1.25, Fees and Financial Arrangements
and, to 5.01, Discussing the Limits of Confidentiality. Standard 4.01(a)
states that "Psychologists discuss with clients or patients as early
as is feasible in the therapeutic relationship appropriate issues, such
as the nature and anticipated course of therapy, fees, and confidentiality".
Standards 4.01 (b) and (c) describe informing the client if the therapist
is a psychologist who is being supervised or an intern in training.
Standard 4.01 (d) states that "Psychologists make reasonable efforts
to answer patients’ questions and to avoid apparent misunderstandings
about therapy."
Standard 4.02, Informed Consent to Therapy,
describes the process for obtaining consent to psychological interventions.
Standard 4.02 (a) states that "Psychologists obtain appropriate informed
consent to therapy or related procedures, using language that is reasonably
understandable to participants." Standards 4.02 (b) and (c) describe
obtaining consent from persons who are legally incapable of giving consent.
Readers interested in comparing the standards for informed consent to
therapy and informed consent to research are referred to Standard 6.11
and Standard 6.15.
Standard 4.03, Couple and Family Relationships,
is particularly relevant to the issues under consideration in this article.
Standard 4.03 (a) states "When a psychologist agrees to provide services
to several persons who have a relationship (such as a husband and wife
or parents and children), the psychologist attempts to clarify at the
outset (1) which of the individuals are patients or clients and (2)
the relationship the psychologist will have with each person." Standard
4.03 (b) states that "As soon as it becomes apparent that the psychologist
may be called upon to perform potentially conflicting roles ...the psychologist
attempts to clarify and adjust, or withdraw from, roles appropriately."
At the end of Standard 4.03, psychologists
are referred to Standard 7.03, Clarification of Role, under Forensic
Activities. Forensic and family therapy are areas of practice in which
defining our professional role(s) and the nature of the psychological
services we provide are critical.
Standard 4.04, Providing Mental Health
Services to Those Served by Others, states "In deciding whether to offer
or provide services to those already receiving mental health services
elsewhere, psychologists carefully consider the treatment issues and
the potential patient’s or client’s welfare." Standards 4.05, 4.06 and
4.07 address the issue of sexual intimacies with current and former
clients. Standard 4.05, Sexual Intimacies With Current Patients or Clients,
states "Psychologists do not engage in sexual intimacies with current
patients or clients." This standard differs from Standard 1.17, Multiple
Relationships, in that 4.05 provides an absolute prohibition against
such relationships, whereas Standard 1.17(a) is essentially a judgment
rule and instructs the psychologist to determine whether a multiple
relationship "...reasonably might impair the psychologist’s objectivity
or otherwise interfere with the psychologist’s effectively performing
his or her functions as a psychologist, or might harm or exploit the
other party". Similarly, Standard 1.19, Exploitative Relationships states
in Standard 1.19(a) "Psychologists do not exploit persons over whom
they have supervisory, evaluative, or other authority such as students,
supervisees, employees, research participants and clients or patients."
It is interesting to note that Standard 1.19 (b) does provide an absolute
prohibition in stating "Psychologists do not engage in sexual relationships
with students or supervisees in training over whom the psychologist
has evaluative or direct authority, because such relationships are so
likely to impair judgment or be exploitative." In this standard, students
and supervisees in training are given the protection of an absolute
prohibition against potentially exploitative behavior. Standard 1.18,
Barter (With Patients or Clients), strongly discourages, but does not
make an absolute prohibition against, barter. Standard 1.18 states "Psychologists
ordinarily refrain from accepting goods, services, or other non-monetary
remuneration from patients or clients in return for psychological services
because such arrangements create inherent potential for conflicts, exploitation,
and distortion of the professional relationship."
Standard 4.07, Sexual Intimacies With
Former Therapy Patients, consists of both an absolute prohibition and
a judgment rule depending on the time elapsed since termination. Standard
4.07 (a) states "Psychologists do not engage in sexual intimacies with
a former therapy patient or client for at least two years after cessation
or termination of professional services." In contrast, Standard 4.07
(b) is a judgment rule that provides an extensive and rigorous list
of considerations for the psychologist who contemplates a sexually intimate
relationship with a client or patient two years post-termination. The
final two standards are not addressed in the general portion of the
Ethics Code and are only applicable to therapy services provided to
patients or clients. Standard 4.08, Interruption of Services, states
in 4.08 (a) "Psychologists make reasonable efforts to plan for facilitating
care in the event that psychological services are interrupted..." and
4.08 (b) “Psychologists consider the welfare of the client or patient
when ending an employment or contractual relationship.” Finally, Standard
4.09, Terminating the Professional Relationship, states in 4.09 (a)
"Psychologists do not abandon patients or clients.” 4.09 (b) states
"Psychologists terminate a professional relationship when it becomes
reasonably clear that the patient or client no longer needs the service,
is not benefiting, or is being harmed by continued service.” Standard
4.09 (c) addresses the responsibilities of the psychologist in terminating
treatment.
We strongly encourage psychologists to
clearly define their professional relationships. Whatever your theoretical
orientation, it is important to differentiate between therapy services
provided to a patient or client and other psychological services provided
to the public. This distinction is especially important when providing
services that are more commonly misunderstood such as couples and family
therapy and consultation. The APA Ethics Code clearly sets a higher
standard for therapy services and provides more protection for therapy
patients and clients. Similarly, state psychology boards tend to set
high standards for services provided to members of the public who may
be more vulnerable and in need of special protection.
AUTHOR
Dr. Wise has a part-time private practice in Chapel Hill, NC in addition to her teaching responsibilities. She is Chair of APA’s Committee on Professional Practice and Standards, and Vice Chair of the North Carolina Psychology Board.Director, Psychology Clinic and Clinical Associate Professor, Department of Psychology, U. of North Carolina, Chapel Hill.