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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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