Another Ethical Quagmire

Another ethical dilemma has arisen for me this week, in the context of the partial hospital program where I work. Specifically, a current client's cousin may be referred from our inpatient unit to the PHP. My client is understandably reluctant to have a family member present in treatment with her (beyond the standard meetings with immediate family, which don't include the rest of the group, and still leave the majority of treatment separate from family). However, management does not consider that sufficient reason not to accept the cousin.

I have serious misgivings about the idea of attempting to treat clients who are related to each other in the same group program. I've had to stop and think about it more to try to articulate my reasons. My initial reaction was that it should be obvious we can't accept the cousin - an assumption I made because it has been the policy at all the other places I've worked that relatives cannot be in group treatment together, nor can they be seen by the same outpatient providers. Since it is apparently not as obvious as I thought, here are what I consider the relevant issues:

1) Dual Relationships
Obviously, family members have an existing relationship with one another outside of treatment. By accepting them both into the same treatment program, we are putting both in the uncomfortable position of having a dual relationship - family member and group member. Dual relationships are discouraged by professional codes of ethics because they raise the possibility of other ethical issues. Some of those are discussed below, but here I'll focus on boundaries.

Specifically, it can be very hard for clients and clinicians to sort out where one role stops and another begins. What interactions between two related clients are coming out of their relationship as group members, and which coming out of their family relationship? Can there even be group member interactions between them that aren't in some way informed by the family relationship? Nobody can set aside all the things they already know or believe about a person, and limit their interactions to only what they've learned or experienced in the treatment setting. The chances that one will reveal too much about the other, or make judgments and assumptions on the basis of past interactions, is high. On the flip side, it can be hard to leave treatment at treatment, and not have group interactions influence outside interactions. It's hard to compartmentalize, and easy to forget how one knows something.

2) Confidentiality
While both relatives may agree up front to keep things disclosed in treatment confidential...they may not actually do so. There is more temptation to tell other family members what a relative disclosed in treatment, versus what strangers shared. There is also the very real possibility that something from treatment will later be used as ammunition in the heat of an argument. Both are likely aware of this possibility, and may self-censor as a result.

Staff may also (inadvertently) struggle with confidentiality. Just as it may be hard for related clients to separate what they know from outside treatment, and what they know from inside treatment, it can be hard for clinicians to remember what they learned from one client, what they learned from the other client, what the clients said in private, and what they said in group.

3) Conflict of Interest
This may be the most concerning aspect of this dilemma for me. The primary "interest" - priority/responsibility - of the clinician is the client's welfare. Whenever there are multiple clients (e.g., group, couples or family therapy), there is potential for a conflict of interests - something that's good for one might be bad for another. The clinician faces a definite conflict - internally and externally - whenever faced with that kind of choice.

The most often cited example occurs in family therapy when the clinician has to file a report of possible child abuse/neglect. While the clinician notifies the whole family of her legal obligations at the beginning of treatment, it still usually causes problems when a report actually has to be filed. The decision is made easier, however, by clear legal standards (i.e., mandated reporting) and the general ethical guideline to advocate for the most vulnerable/least powerful person's interests.

Assuming no clear power differential between our potential related clients, a conflict of interests between the two would be much harder to resolve. Imagine, for example, they have an argument, and both declare: "If she continues treatment, I'm dropping out!" Assuming neither budges from this position, even after a cooling-off period and talking with staff and peers, the treatment team is faced with quite the dilemma: there are two medically and psychiatrically compromised individuals who want treatment...but not if the other one is present. We might choose the more medically unstable, or the least ready for discharge, but the other one might reasonably claim that we did not fulfill our obligation to her. We might decide to discharge both, to avoid any claim of discrimination against one, but we'd have to find some way to ensure adequate aftercare for both. Yes, it would be quite the quagmire.

There is also the question of whether a conflict of interests already exists if we accept one and not the other. My contention is that our primary responsibility is to the client who has already been admitted to our program. The other is on an inpatient unit within the same agency, so some may say that we have a responsibility to her as well. However, I disagree - the inpatient team is responsible for her treatment, and arranging reasonable aftercare. If she can't come to us, that means they need to find a way for her to go elsewhere, or access a different level of care (IOP vs. partial, perhaps), or have more frequent outpatient appointments and monitoring until her relative discharges and she can start our program. There are solutions. Our responsibility is to ensure the best possible treatment for the client we already have.

It seems clear to me that dual relationships, possible breaches of confidentiality (and self-censorship out of fear of such a breach), and conflicts of interest would interfere with the quality of treatment for both. Instead of providing good treatment to one, we're providing treatment to both that is only ok...at best. That is not ethically sound, damages our reputation in the community, and could influence our reimbursement by insurance...and that's not even considering the cost to the individual clients in unresolved symptoms and ongoing struggle. But, again, this is just my opinion.