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Marital Therapy Vignette

Marital Therapy Vignette -  Vignette Discussion to “Treating Couples: Identifying and Managing Legal & Ethical Issues

Michael Griffin, JD, LCSW
Staff Attorney
The Therapist
July/August, 2012


Vignette#1 
Mary contacted Tom, a Marriage and Family Therapist, to inquire about the possibility of participating in marital therapy with her husband, Aaron. During their third marital session, Aaron announced that he would no longer be attending marital therapy. In Aaron's opinion, the previous two marital sessions demonstrated to him that his marriage couldn't be saved and that further marital therapy was a waste of time. Aaron then stated that Mary should continue in individual therapy with Tom if she wanted to and that "the least he could do" was pay for Mary's sessions. Aaron then apologized for the fact that he had to leave the session twenty minutes early and left the office.

Questions applicable to Vignette#1:

  1. Under the circumstances described in Vignette #1, should Tom consider this session to be his final (termination) visit with Aaron? If "yes," why? If "no," why not?
  2. Under the circumstances described in Vignette #1, should Tom provide individual therapy to Mary? If "yes," why? If" no," why not? Is there any additional information that you would like to have to answer this question? If so, what information would you like to have?
  3. How should Tom respond to Aaron's comments about paying for Mary's therapy?
  4. If Tom agreed to accept Aaron's offer to pay for Mary's therapy, assuming that she decided to participate in such therapy, what should Tom do if Aaron ultimately refused to pay for her sessions?

Discussion:

  1. Aaron did clearly state that he would no longer be attending therapy with Tom. However, the nature of Aaron's departure was certainly dramatic and unusual. It would be prudent for Tom to consider contacting Aaron to discuss what transpired, to confirm Aaron's decision not to continue, and to offer a referral to another therapist, if appropriate. Tom should take care to document his effort(s) to communicate with Aaron, and Aaron's response, or lack thereof.
  2. Under the circumstances, Tom would be permitted to provide individual therapy to Mary, so long as Tom is sure that the marital treatment has concluded. If Tom began to provide individual therapy to Mary, he would need to close the marital treatment record, and open a separate, individual therapy record for her.
  3. To begin with, Tom could not directly accept Aaron's offer to pay for Mary's treatment. Aaron would have to discuss his offer with Mary. Having said that, Tom would not be obligated to agree to such an arrangement, if he believed that it would be clinically inappropriate to provide therapy to Mary under such terms. Although such an arrangement would not be strictly prohibited, there would be a strong possibility of boundary problems arising as a consequence.
  4. If Aaron ultimately refused to pay for Mary's sessions, Tom would be expected to discuss the matter with Mary and to consider what would be reasonable and appropriate for Mary's treatment. If Mary was unable or unwilling to pay for continued therapy with Tom, Tom would not be obligated to continue to provide ongoing therapy to her, but any termination of her treatment would have to be conducted in an appropriate manner, in consideration of her needs at that point in time.

Vignette#2 
Rose provided weekly individual therapy to Jonathan for about six months. During that period of time, Jonathan's wife, Sue, agreed to participate in some conjoint sessions with him and Rose, in order to help Jonathan address some of his individual issues. Although Nathan and Sue both found those sessions to be productive, Jonathan was particularly encouraged by the positive changes in his relationship with Sue. Later, Jonathan persuaded Sue to join him in marital therapy with Rose. Based on her belief that the various issues addressed in the therapy sessions were closely related, and to simplify her recordkeeping, Rose documented all of the therapy sessions that were provided to Jonathan and Sue in a single treatment record.

Questions applicable to Vignette #2

  1. Was it appropriate to include Jonathan's wife in collateral visits with Jonathan during his individual therapy? If "yes" why? If "no," why not?
  2. Was it problematic to provide marital therapy to Jonathan and Sue at the conclusion of his individual therapy? If "yes," why? If "no," why not?
  3. Was it problematic for Rose to document all of the therapy provided to Jonathan and Sue in a single treatment record? If "yes," why? If "no," what would have been preferable?
  4. How should Rose respond if either Sue or Jonathan requested a copy of the progress notes for the marital sessions?

Discussion:

  1. It would be appropriate to include Sue in some conjoint sessions with Jonathan, so long as everyone understands, and agrees with, the intended purpose of those sessions. The therapist must take care to avoid the possibility of confusion, or misunderstanding, as to the nature of the treatment plan, the intended goals, and/or who the patient actually is.
  2. It was problematic to provide marital treatment to Jonathan and Sue at the conclusion of his individual therapy, if Sue was pressured into participating in that treatment. Sue attended the sessions with her husband initially, for the purpose of assisting him in addressing some of his individual issues, not to work on their relationship. It may be difficult for Rose to maintain an objective perspective regarding the marital relationship and an objective perspective regarding Sue, because of her prior individual relationship with Jonathan. Therefore, there is a potential conflict of interest for Rose, in attempting to provide marital treatment to this couple, subsequent to her individual work with Jonathan.
  3. It was inappropriate for Rose to document the marital therapy in the same record that was used for Jonathan's individual therapy. There were two separate treatment episodes to be considered here, involving two separate "patients." The fact that Sue attended some conjoint sessions involving Jonathan did not change the fact that Jonathan was an individual therapy patient at the time. Later, at the time when marital treatment officially began, the identified "patient" was the marital couple.
  4. If either Sue or Jonathan requested a copy of the marital therapy progress notes, it would be necessary for the therapist to obtain the permission of both individuals in order to release the information. Where the patient is a couple, rights of confidentiality are jointly held.

Vignette#3 
After participating in marital therapy with Tom for a few months, Ronald and Michelle decided to pursue a trial separation. The couple agreed that Tom was a good therapist, and they decided to ask him if he could facilitate a discussion on the topic of co-parenting their ten-year-old daughter Lisa. Although Tom was reluctant to assist them with these issues, Ronald and Michelle stressed that they were extremely concerned about Lisa's reaction to their separation and they agreed that Tom was the "best person" to assist them in discussing a temporary agreement, because he already knew them and was familiar with their concerns. Tom made a point of telling them that he would assist them, so long as they clearly agreed not to involve him in any subsequent litigation that may arise concerning the issues of custody or visitation Ronald and Michelle quickly agreed to Tom's terms, but Tom said that he wanted to "play it safe" and had them sign an agreement promising not to involve him in any litigation. After meeting a few times, Ronald and Michelle both informed Tom that they were pleased with the outcome of their discussions regarding Lisa's care and thanked him for his help. About one year later, Michelle contacted Tom to inform him that she and Ron were involved in a very contentious divorce. Michelle asked Tom if he could have a few sessions with Lisa "to see how she was coping with everything."

Questions applicable to Vignette#3

  1. Was it problematic for Tom to help Ronald and Michelle form a plan for co-parenting their daughter Lisa during their trial separation? If "yes," why? If "no," why not?
  2. If Tom or Michelle decided to subpoena Tom to testify at a deposition or hearing regarding their discussions in therapy, can Tom refuse to appear in Court, based upon his earlier agreement with them concerning his possible involvement in litigation?
  3. How should Tom respond to Michelle's request to meet with Lisa?

Discussion:

  1. When Tom agreed to assist Ronald and Michelle with co-parenting issues, he should have considered the fact that the couple were recently separated and likely to become involved in litigation in family court involving the care and custody of their daughter. Although that fact alone doesn't preclude the couple from asking a therapist for help, it was naive of Tom to think that he could help them to develop a temporary agreement on this topic without becoming involved in subsequent related litigation. The fact that Tom asked them to sign an agreement 
    not to involve him in legal matters would not prevent them from calling him as a witness at a later time. Furthermore, the court would likely not be concerned with the fact that these individuals previously made an agreement not to involve Tom in litigation.
  2. Tom would be required to appear at a hearing or deposition if he was properly served to do so.
  3. Lisa's request in this instance is quite common. Such a request usually results in the therapist being asked to testify regarding his or her impressions of the minor child. If the therapist provided his or her opinion regarding issues such as custody, visitation, or the competency of one or the other parent, the therapist faces the possibility of a disciplinary action against him or her by a licensing board, an ethics complaint, or a lawsuit for malpractice.

Vignette#4 
David provided individual therapy to Anne, a particularly rebellious 15 year old. After almost 18 months of therapy with David, Anne said that she had had enough treatment and wanted to "take a break for awhile." Anne's parents agreed with David's recommendation that it was "ok" to give Anne some space, and they allowed her to discontinue therapy. Shortly thereafter, David met with Anne's parents to work on some co-parenting issues, but the meetings evolved into marital therapy that lasted nearly a year. Eventually, Anne's parents decided that she should return to therapy with David due to her failing grades.

Questions applicable to Vignette#4

  1. What issues exist, (if any), with respect to the manner in which termination was handled with either Anne or her parents?
  2. Did David encounter any potential conflicts of interest in providing treatment to Anne or to her parents? If so, please discuss and indicate how David might have responded differently at any point in time.
  3. What issues exist, (if any), in vignette #4, with respect to the issue of consent to treatment? If you were David's consultant, please discuss any suggestions that you might wish to offer to him regarding this issue.

Discussion:

  1. When Anne said that she wanted to "take a break," it was unclear whether her therapy was explicitly discontinued or whether an appropriate termination took place. In such 
    circumstances, it is difficult for the therapist to say with any degree of certainty, whether the therapeutic relationship with his or her patient is continuing, or not. It is always important for the therapist the therapist to clarify whether the client's treatment has discontinued, or not. The record should include the therapist's comments on the termination process, the reasons for terminating treatment, and include any recommendations given to the patient.
  2. Depending on the specific facts and circumstances, it may have been appropriate for the therapist to provide assistance to the parents regarding co-parenting issues. But it is likely to be problematic for the therapist to embark on a course of marital therapy with the parents of his or her current, or former, 15 year old patient. Generally speaking, the adolescent patient's trust in the therapist would be threatened or potentially harmed by such a decision and there would be a potential/likely conflict of interest associated with the provision of concurrent, or subsequent therapy to different individuals within the same family system.
  3. There is a potential problem involving Anne's consent in this case, because it is stated that her parent's decided that she should return to therapy, due to her failing grades. In light of the fact that Anne stated earlier that she had "had enough" treatment, the therapist would need to evaluate whether Anne is interested in, or receptive to, the re-initiation of treatment. Every situation is different and there are times when it can be very difficult to determine whether an adolescent is participating in therapy on a truly "voluntary" basis. While it is not unusual for adolescents to be brought to treatment, that fact alone does not mean that the patient can, or should be, forced to accept treatment against his or her will.