Consider this scenario: you are a direct service provider offering mental health counseling to individuals and families. A young woman and her mother visit your office seeking assistance with their personal relationship. You elect to assess them together during their first visit. Each asserts that she has felt depressed in recent weeks and attributes her sad feelings to the fact that the young woman, who is 30 years old, has had to move in with her mother, 52, after a failed marriage. In talking to mother and daughter together, you reach the clinical conclusion that each may be suffering from mild depression and would benefit most from individual psychotherapy. You practice in a rural community in which the number of clinical providers is small, and you consider the possibility of providing individual services to each woman separately. Can you do this legally and does a conflict of interest prevent you from treating each woman separately as an individual client?
In order to address this dilemma, it is helpful to review the material presented in this website concerning the duty to identify the primary client. You reach the conclusion that your clinical assessment reveals that each woman would benefit most from individual psychotherapy, and therefore you are willing — at least preliminarily — to assume a therapist-client relationship with each separately. Is there a conflict of interest presented by this choice? In theory, your treatment of one family member could well cause you to receive information and to allow your independent treatment stance to have an impact on the other. For example, the daughter might assert that her mother’s “abusive attitude” is at least partially responsible for the difficulties she is now experiencing in her life. Similarly, the mother might assert that her daughter’s move back into her household has created tensions between them that are leading to the emotional problems being experienced by both women. Is it possible for you to administer clinical services to both women without allowing information gleaned from each client to influence your treatment of the other? In view of this problem, wouldn’t the provision of services to each woman run counter to best practice standards governing the avoidance of conflicts of interest?
It would be quite rational to answer this question in the affirmative and simply discontinue services with one, or perhaps both, women, in the reasonable belief that your ability to provide independent clinical services will be compromised if individual treatment of both continues. On the other hand, let’s deal with the reality that both women are in need of services that will likely not be provided at all — given the unavailability of clinicians in your rural community — if you don’t agree to provide these services to each woman yourself. This is a problem that rural practitioners face every day, and it is clear that professional codes of ethics often give confusing and sometimes contradictory advice on the management of such situations. If one examines the duty to seek informed consent, a topic discussed in further detail in this website, one finds that it is prudent both clinically and professionally to discuss the risks and possible benefits of providing services to both women before a decision is made either to continue independent services or discontinue them. If the clinician thoroughly discusses the potential dangers of treating both women with each client — including the possibility that the clinician will allow revelations from interactions with each client to influence the practice stance assumed with the other — it may well be concluded that this risk is worth assuming. The reason for this is that the risk of providing services under these circumstances is worth assuming when one considers that avoiding the risk entirely will result in no services being provided at all. After a thorough discussion of the risks involved, a competent mental health practitioner may well reach the conclusion that the decision to continue separate clinical services with both women is both reasonable and in both clients’ best interests. Comments from readers on this discussion are greatly appreciated!