"In Treatment"
Therapeutic Boundaries & Ethical Issues in the 2nd HBO TV Series

Dual & Multiple Relationships

In the first episode Paul, a therapist, arrives at a law office to find that his former client, Mia, is now his defense attorney in a malpractice suit against him. He soon learns that this sequential dual relationship, unbeknownst to him, was deliberately initiated by the former client who “grabbed” the case for herself. Paul’s therapist, Gina, and Paul are engaged in sequential multiple relationships. Gina was Paul’s supervisor and the couple’s therapist for Paul and his estranged wife. At the present time, she is Paul’s individual therapist and also his estranged wife’s individual therapist

Note: Sometimes dual relationships are unavoidable (such as in small, rural, church, LGBT, minority communities), mandated (such as in the military and correctional institutions), unexpected (this can happen anywhere and any time) or initiated by the client (such as with Mia in In Treatment). A movie that similarly presents unexpected and unplanned dual relationships is Prime. What about Bob presents multiple relationships that were initiated by the client. Not all dual or multiple relationships are created equal. They can be concurrent or sequential, simple or complex, ethical or unethical, accidental or deliberate, and voluntary or mandated.

There seems to be agreement that providing psychotherapy and clinical consultation at the same time is not a good idea in most situations, due to conflicting roles and responsibilities. Similarly, providing therapy to students who concurrently are attending the therapist s class should be avoided, if possible. (In situations where it is not possible, extra precautions must be taken.) In my opinion, there is no consensus about the ethics of sequential dual relationships where a student seeks therapy from his/her former instructor-professor. Generally, it is less complicated if the therapeutic relationship comes after the professor-student relationship compared to the other way around. Each situation is different and sometimes even complex dual relationships cannot be avoided in small or rural communities and in educational and training institutions. Making the shift from a consultant or supervisor role to the therapist role can be appropriate, depending on the therapist, client, timing, setting, relationship, and form of therapy. Again, it all depends on the context of therapy.

Further Resources:
Dual Relationships Brochure
Online Course: Dual Relationships

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Power Relationships

Mia plays the power card aggressively. She flaunts her expensive high-rise office, her numerous certificates and awards, and alludes to the fact that she now makes more money than Paul. Obviously, she has the power of information. She is aware of what Paul is accused of. She also intercepts, opens, and reads documents containing information about another of Paul’s clients and then throws the documents at his feet in an accusatory, confrontive manner. She is also powerfully aware of Paul’s sexual transgression with a former client. Finally, she exerts her own sexual power by being provocative with him as she graphically details erotic sexual experiences.

Note: We need to re-think the common attitudes regarding the power differential between clients and therapists, which claim that therapists are always more powerful than their clients. While therapists have Role and Legitimate types of power, many clients carry power over their therapists in other ways. Therapists may lose power when they find themselves sexually attracted to a client.

Further Resources:
Article on Power
Online Course: Power in Therapy

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Self-Disclosure

Paul routinely discloses his feelings about his clients. He expresses outrage at April, a young woman client who is medically non-compliant with her chemotherapy. He is also affectively demonstrative with facial expressions and gestures. He self-discloses by having a child’s drawing in his office. As noted below, the home office intrinsically involves extensive self-disclosure. He disclosed to Mia and to April that his father had just died, both disclosures were clinically appropriate within the context of these relationships. He also shared with April that he was not close to his father and that his mother had been dead for quite some time. In the last session of the 2nd season, Paul disclosed to April about his failed marriage and that his children lived with their mother. This self-disclosure was clinically appropriate as it normalized to April that suffering and failure is part of the human condition. Towards the end of her last session, Paul gave April a hat and disclosed to her that this was his father’s hat, which added significance to his departing gift.

Note: Self-disclosure is an important clinical tool and one of the better predictors of positive therapeutic outcome. Self-disclosure can be verbal or non-verbal and intentional or unintentional.

Further Resources:
Articles on Self-Disclosure
Online Course: Self-Disclosure

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Clients Googling Therapist

Mia checks out Paul’s FaceBook profile and finds out that he is single. She then launches into probing questions about his divorce and family situation. Walter, the executive, does a “background check” on Paul and also finds damning information.

Note: In the Internet era many, if not most, of our clients view themselves as ‘consumers’ and are likely to Google their therapists. They can easily access online public records, including marriages, births, divorces, legal issues, debts, political affiliation, sexual orientation, and much more.

Further Resources:
Article on The Google Factor
Online Course: Self-Disclosure

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Proximity – Distance – Location

Paul seems to be comfortable varying the distance between each client and himself. He sits on the floor and stands in the kitchen next to young Oliver, and he walks beside April as they are ready to leave the office for chemotherapy. He moves out of the office and into the waiting room with Oliver, thereby sheltering him from his parents’ argument. In the fifth session, Paul stands beside Oliver right after he sets a boundary with the parents’ fighting.

Note: Different clients and different situations may require different proximities (for instance, different sitting or room arrangements).

Further Resources:
Online Course: Boundaries

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Leaving the Office

Paul observes that April is unable to get herself to her chemotherapy appointments, nor is she able to ask her mother or others for help. She cannot break out of her paralyzing fear and family role behavior. In this situation, Paul decides to take April to her chemotherapy session himself. Paul makes a hospital visit to Walter after Walter’s suicide attempt. He then makes a suicide evaluation at Walter’s bedside. When Oliver ran outside the office in the fifth session, Paul followed him to the nearby park where Oliver and he talked about Oliver’s concerns and hopes while sitting side by side on the swing set

Note: Out-of-office experiences can be very therapeutic and essential to healing. Home visits, attending a wedding or confirmation, or accompanying clients to important medical appointments can be an important part of treatment. Sometimes a (side by side) walk on a trail can be more beneficial to some clients than the more formal face to face setting of the therapy office. Adventure therapy, obviously, is being conducted outside the office.

Further Resources:
Article on Therapy Outside the Office
Online Course: Out-of-Office Experiences

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Touch

Paul physically supports Walter, an elderly successful CEO who has suffered a panic attack during session, and reassuringly touches young Oliver. When Walter broke down sobbing in the fifth session, Paul approached him slowly and touched his back gently as Walter clenched Paul’s leg in tears and despair.

Note: Fifty years of extensive research has made it clear that touch has numerous clinical applications and, at times, can be more therapeutically effective than words.

Further Resources:
Article on Touch in Therapy
Online Course: Touch in Psychotherapy and Counseling

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Gifts from Clients and from Therapists

Paul received cookies from Bess. Some may consider the sandwiches he served Oliver also as gifts. Paul gave April a personal and meaningful gift in the last session of the 2nd season, his father’s hat. The gift is appropriate as the hat that April got from her brother is itchy and uncomfortable to her post-chemotherapy bald head. Paul disclosed to April the fact that he got the hat from his father, which signified to April that she was cared for and attended to in a variety of ways.

Note: Giving gifts is an ancient and common and human way to express gratitude, appreciation, and care. Gifts in psychotherapy and counseling are very common and often take place around the holidays, with children-clients, in termination, at an important junction of therapy. Therapists have not only received gifts but have also been regularly engaged in gift giving to clients. Usually therapists’ gifts have clinical significance and involve appropriate symbolic gifts, greeting cards, transitional objects, or psycho-educational material, such as books, audiotapes or CDs. Appropriate gifts by therapists to clients and by clients to therapists are ethical and can benefit the therapeutic process. Rigidly rejecting clients’ gifts can be insulting and harmful to therapy.

Further Resources:
Article on Gifts in Therapy
Online Course: Gifts in Psychotherapy and Counseling

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Serving Food & Other Boundaries

Paul, appropriately, is much more flexible in his boundaries with his child client and his specific clinical needs. When he realizes that Oliver has been starving himself, he takes him into his kitchen and makes him a sandwich. In an earlier segment, he takes care of Oliver’s turtle, inadvertently (unconsciously) left behind at the end of a session.

Note: Flexibility in our intervention is the hallmark of effective psychotherapy. Different clients have different needs and different ways. Acting out of fear or following rigid risk management guidelines can be counter-clinical and even unethical or harmful.

Further Resources:
Article on Risk of Risk Management
Online Course: Boundaries & Movies
Online Course: Risk of Risk Management

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Home Office

Paul is using a home office, which creates a rich and complicated environment. His humble, home office in Brooklyn hints at his economic status. Practicing in a home office engenders questions and assumptions from his clients and calls upon him to make boundary decisions that would not come up in a traditional office setting. Oliver asks what is behind each door and tries to imagine Paul’s relationship with his own son. Mia barges into the kitchen in an attempt to “be special”. The setting also involves photos and many other personal details providing windows into Paul’s personal life.

Note: Home office settings always involve extensive self-disclosure that must be taken into consideration in the clinical work.

Further Resources:
Online Course: Home Office

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Use of Cell Phones in Sessions

Another boundary that seems to be more common these days is when clients receive or make cell phone calls or text messages during sessions. The issue of cell phone usage presented itself in sessions with Mia, April and Walter.

Note: Clients receiving or sending phone messages or texts during therapy sessions has become very common. Many clients do not think much about texting during sessions. Generation Net clients do not think much about multitasking during therapy sessions. Therapists must take into consideration the evolving technological new attitudes towards this and respond in a clinically appropriate and flexible manner.

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End of Life Issues

The series subtly raises several issues regarding end of life and the clients’ right to die. Paul is facing a wrongful death lawsuit after he cleared a distressed and depressed navy pilot, Alex, to fly. As a result, he is hyper-focused on the question of where he stands holding the tension of his responsibility to “save lives” versus the desires and decisions of his clients. Paul insists that April get immediate treatment for her cancer with the understanding that taking no action would be suicidal. He accompanies her to her first chemotherapy, an appointment she would not go to by herself. He decides that Walter, the disgraced elderly CEO who was hospitalized after a failed suicide attempt, is a danger to self and he recommends involuntary hospitalization. In a “cliffhanger” preview clip, we see Walter in Paul’s face demanding, “I want out!”

Note: End of life issues, right to die, and assisted suicide are highly legally, morally, and ethically complex issues. It is likely that there will be increasing tension between the opposites on this issue as baby boomers move toward their final days and press for the right to die. On one side, assisted suicide is still illegal in most states. Then, most therapists have an ethical and/or legal mandate in situations when clients present “danger to self.” On the other hand, therapists have an ethical obligation not to impose their values on their clients and to support and respect their decisions about their lives and their death, especially when the decisions are rational and well thought out. As therapists stand at the junction of life and death, they must deepen their understanding of the complexities of these issues, acknowledge their biases, admit to their fears, and ultimately, develop a thorough ethical and moral decision making process to handle the end of life issue with integrity and care

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