Must I Terminate with this Client, or Allow them to See Me in Private Practice?
Q: My family and I are in the process of relocating to a different part of the state. I have given my notice to the community mental health center for which I have worked for several years, and have opened a private practice in my new community 310 miles away.
When I began telling my clients about my move and my leaving the agency, several of my long-term clients expressed a wish to follow me to my new practice rather than transfer to another therapist at the agency.
My question concerns one of these clients. The client has made two trips to the new office, but her financial situation makes it difficult or impossible to be able to continue doing so. She and her husband are in bankruptcy due to huge medical bills, and they are losing much of their quality of life as a result.
She values the connection counseling offers her and does not wish to see another therapist at this time. She still has insurance through COBRA.
I am planning on staying a bit longer in my old community before making the final move, but have ended my work at the agency. I would like to be able to continue seeing this client while I am still here, but do not have an office in which to meet. Is it ethical for me to see her in a setting other than a therapy office?
A: I have several reactions to your question and hope you don't mind my commenting on more than just what you've asked.
I'm not sure what type of places you are thinking of in which to conduct a session, but regardless, it is important to be conscious of the fact that it will feel different to the client (and probably you), and due to not meeting in an "office" the likelihood is both of you will have some tendency to behave differently in relation to each other because some of the usual boundaries have changed due to the change in setting. A less formal setting may lull you both into relating less formally (or professionally), and more like friends or personal acquaintances. The responsibility will fall on you to bring up the change in setting as a topic, and engage your client in a conversation about the possibility of this change affecting how the professional relationship "feels", and how important to your work together it will be for you to safeguard the professional boundaries so that the work is not diluted or lost.
I would think it important for anyone in such circumstances to keep in mind that this change creates a bit of a slippery slope and ethically it falls on you to maintain the boundaries and therapeutic relationship. Given the client's current vulnerability due to her life circumstances, this would be a time most clinicians (regardless of where you are meeting) would have trouble maintaining normal treatment boundaries and not giving in to the human impulse to offer comfort rather than therapy.
Now this is the part that you did not ask about, but which raised a question for me. If I were your clinical consultant, I would ask you if you had any thoughts about how it is that "several" of your clients are saying they would prefer to commute 620 miles rather than consider working with a different but local clinician. Of course I understand any client's preference not to have to start over with a new therapist, but that commute is not a practical one for most anyone, unless they are already routinely making the commute for other purposes. Maybe they would make the drive once or twice, but then they would likely drift off and you won't have gone through the termination process that clients need. Or, they would only manage to see you sporadically and perhaps not as often as would be clinically indicated. My guess is that they are wanting to avoid the loss of you, and perhaps by agreeing with them you are colluding with them in this avoidance.
I remember what it was like to leave my clients at the community mental health agency in which I worked years ago. It came at very difficult periods of time for several of them and I felt horribly mean and selfish for leaving during that period because I could see and feel the pain it caused for them. If I had given in to this (and stayed or facilitated their following me into my private practice), I believe I would have been indulging my own fantasy that I was the best person to be working with those clients, and that somehow dealing with the loss of me in their life was not a loss they could get past. Loss is a part of life and many of us don't handle it well. Leaving your clients gives you a chance to model for them how to deal with loss, how to express all the feelings they have in response to it, and come out intact on the other side of it.
This scenario also reminds me of instances where a client moves out of the area or out of state and makes a plea for their counselor to agree to counseling by telephone so the client won't have to begin again with a new therapist. I think that as clinicians we would have a difficult time justifying going along with that plan. Maintaining some connection while helping them find & transition into working with a new & local therapist is more the standard of care.
I hope it is OK with you that I responded to more than you asked about. Good luck with this. And you're welcome to write again if you think it would be helpful.
Older Minors & Their Confidentiality Q: I have heard two separate views about the confidentiality of minors’ records and what is said in their sessions. Assuming that child abuse and duty-to-warn doesn't apply, does a minor from the ages of 13-17 have confidentiality from their parents? I have frequently heard that they do and have found a WAC that says that the information older minors share is confidential. But, I heard at the HIPAA workshop that they don’t. Do you know? Usually, I get around this issue by telling the parents that this age group "likes to have a safe and confidential meeting with their therapist," and if there is anything that I think the parents need to know, like duty-to-warn, drugs, dangerous acts, etc., I will encourage the youth to share that with their parents in a joint session. I make this statement with both parents and the kid present so everybody knows what my policy is. But I am very curious about what the law really says. I called the State and they seem to think that a youth from 13-17 could get treatment without parents’ consent and have confidentiality. What do you know about it?
A: I know exactly the confusion you are talking about, and I also feel a bit stuck. The attorneys who specialize in mental health law in WA State disagree about this. There is that law (RCW 71.34) that says that minors 13 & over can consent to their own treatment and by default then, control their confidentiality. Some attorneys take the position that this applies only in DSHS-contracted treatment facilities (like community mental health centers) because that chapter (RCW 71) is written about services provided in those settings. These attorneys take the position that other than that one chapter that is focused on one form of treatment setting, the default law indicates that minors under 18 cannot enter into any legally binding contract (treatment or otherwise) and therefore do not have confidentiality from their legal guardians. They also say that in a DSHS-funded facility, the minor over 13 can get treatment without parental consent and can control their own confidentiality. Minors over 13, they say, when receiving treatment in private practice settings, must have their parents sign the consent-to-treatment and the parents have access to information about the content of treatment, if they choose. Obviously (as you have encountered) other legal minds disagree or are surprised to hear this logic and hadn't previously considered it. There has been no case law to determine how this should be interpreted or will be interpreted by the courts. My solution is to get the parents and the older minor to sign the consent-to-treatment in my private practice, and to make an informal contract with parents to not request private info about the content of their older minor's sessions. I make the same explanation as you described using. The legal confusion is frustrating, but seems to be the way it is...
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