♦ The "Rational Suicide" Question
Suicide brings up the conflict with your client's needs versus your client's rights related to setting ethical boundaries. One purpose and a significant feature of the therapeutic relationship is the process of enabling clients to exercise and increase their ability to participate in the therapeutic decision making. The individual's right to and need for self-determination are areas in which we often get confused, because of the social implications.
When one person's exercise of self-determination adversely affects another, the necessity for some limitation becomes obvious. However, this necessity does not negate the existence of the need for self-determination as part of the relationship. A major area of therapeutic controversy is that of the belief in rational suicide.
In short, for example, for a severe burn patient in constant pain whose self-determination is an all consuming wish to die, where do you draw the ethical boundary concerning your responsibility to protect your client from harming him or herself? Thus, the ethic of self-determination is at odds with the ethic to protect one from harming him or herself.
♦ Time Limit Boundaries
Keep in mind the setting expectations: the Duty-to-Warn and Protect. Let's relate it to one definition of therapy. By definition, therapy is purposeful and goal directed. It is directed toward enabling the client to achieve a more satisfactory degree of functioning.
A boundary is set because the relationship is time limited. This seems pretty obvious. When the purpose is served and the goal achieved, the specific relationship is terminated. It is also an unequal relationship, as I mentioned earlier, in which the therapist and client or patient have differing roles and responsibilities - the therapist to give, and the client to receive, help. Therapy is directed to meet the needs of the client through provision of the needed help by the therapist.
However, in this unequal relationship regarding the boundary of time, unnecessarily prolonged therapy tends to become sterile and meaningless, and can create client dependency. As you know, the therapist's role demands teaching clients how to use help, how to use their own capabilities, and where to turn when future assistance is needed.
It is a basic fact in setting boundaries that a helping relationship is geared to meet the needs of clients and not that of the therapist. Yet, as we discussed earlier, if the needs of the therapist are not met, for example regarding conflicting feelings toward the client, the therapist will not be able to function to his or her fullest potential.
♦ Your Paycheck vs. Your Principles
For example, ask yourself, "When is an issue resolved to the point where I recommend to the client that he or she no longer needs therapy?" Or, when is an issue to the point of needing a referral to another therapist with expertise in a different area that would better suit my client's goals? It would be wonderful if therapists were independently wealthy, but in the back of your mind you may know that ending the therapy relationship also means less money to pay your bills at the end of the month. Ask yourself, "If my paycheck depends on my caseload, what am I doing to reconcile the time limited nature and the basic premise of the therapeutic relationship of meeting the client's and not my needs?"
- Stone, M. (1999). Boundary Violations between Therapist and Patient. Psychiatric Annals, 670(7).
Peer-Reviewed Journal Article References:
Barnett, J. E., Behnke, S. H., Rosenthal, S. L., & Koocher, G. P. (2007). In case of ethical dilemma, break glass: Commentary on ethical decision making in practice. Professional Psychology: Research and Practice, 38(1), 7–12.
Magnavita, J. J., Levy, K. N., Critchfield, K. L., & Lebow, J. L. (2010). Ethical considerations in treatment of personality dysfunction: Using evidence, principles, and clinical judgment. Professional Psychology: Research and Practice, 41(1), 64–74.
Mayer, D. M., Ong, M., Sonenshein, S., & Ashford, S. J. (2019). The money or the morals? When moral language is more effective for selling social issues. Journal of Applied Psychology, 104(8), 1058–1076.
Muran, J. C., & Eubanks, C. F. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture. American Psychological Association.
Pinner, D. H., & Kivlighan, D. M. III. (2018). The ethical implications and utility of routine outcome monitoring in determining boundaries of competence in practice. Professional Psychology: Research and Practice, 49(4), 247–254.
Ethics CEU QUESTION
What can be the end result of unnecessarily prolonged therapy? To select
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