Adjunct teaching and clinical work conflicts

[AbnormalPsych]

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Hi all,

Hypothetical scenario, but something that crossed my mind recently and thought could lead to some interesting discussion.

Say your full time job is a clinical one in a major medical center. You work on a treatment team (a lot of groups) in addition to providing individual therapy. You see many patients over a year - and most are likely to remember you given your frequent presence in group. You also adjunct teach a few undergrad and graduate courses in the community here and there.

One day you notice a former patient's name is on one of your class rosters. The class has not started yet, but week 1 is next week.

How do you proceed?

 

[foreverbull]

Talk to the student in private? Let the student know that it’s considered inappropriate to have an evaluative role after being the student’s therapist in any capacity and urge the student to drop the course/change sections? I suppose we’re assuming the student knows the teacher is the former therapist and is taking the course anyway?

My initial thought was are we even allowed to acknowledge the prior relationship to the student if the student doesn’t initiate the discussion? But maybe I’m thinking too far on the conservative extreme there.

Either way, I don’t think the teacher can ethically drop the student if the student wants to stay in the class (unless the dual role issue is severe enough that it trumps the student’s agency/choice here, which I don’t think would be the case). My understanding is also that the teacher can’t say anything to anyone at the college if the student stays (even if the teacher said to another faculty member “I cannot teach this student but I can’t discuss why” it could be assumed why given the profession and confidentiality would be breached), so that might require an ethics helpline call....tricky!

I definitely think it’s a concerning situation to be in if there’s a possibility of having treated a person and then later suddenly being in an evaluative role as a teacher to that same person. Seems inappropriate and problematic to me, but I like clear boundaries.

I suppose the dual relationship issue could also be affected by length of treatment and possibly how rare the course is that one is teaching (let’s say this was taught only once per year and you are the only person who teaches it at your college—is it fair to tell the student to drop if he/she/they are a senior and needs this course to graduate?). And was this person seen only once (I.e. very brief interaction like an intake years ago, and you barely remember this person and the person may not remember you), or was this an ongoing therapy situation? Wondering if these factors matter. Regardless, I think this dual role situation requires consultation with an ethics helpline to discuss specifics and then documentation.

I’m interested to hear others’ thoughts on this as well.

 

[WisNeuro]

Very much depends on the situation. What if this class is the one class they need to graduate? Are they screwed? Do they just have to waste money and take the class next year? I'd definitely talk to the student first to see the underlying context as to them taking the class. I do agree that an ethical consult would be good. A confidential consult to the dept head or ombudsman could also be helpful. You can explain the situation in general terms without giving up PHI, in most circumstances. There may be the option to have the students' work blindly graded by another instructor, etc. Lots of options, I'd just make sure to explore things fully, consult, and document EVERYTHING.

 

[TherapyCakes]

So I have had this happen twice. With current and former patients. I split my time teaching undergrads and engaging in clinical work, so I assumed this would happen at some point, just did not realize how early in my career I would be presented with it. I also teach a few classes within a small minor that require certain courses (including one that I teach) to be taken for their minor requirements. I am kind of SOL in terms of dictating whether they should take it or not. So lots of consulting with colleagues initially on how to best manage this, how to have this conversation with patients, etc.
The way I have worked around it is via TAs. I am NOT involved in grading basically anything in the course, for any students. That is a complete luxury, I recognize this. I will help with grading if needed, but since my students submit things via an online portal, I have the option to blind myself to the students names on assignments. Otherwise I am mostly just incorporating grades together for final grading / calculating attendance grades, which are objective and laid out in my syllabus. I have never had a student-patient challenge or appeal grades, but if they did it would be difficult to do so since everything is so cut and dry in terms of points and grading.
I have frank conversations about this with patients as well. In one case they were a current patient so could have that conversation ongoing. In the other case I knew in advance that a patient was enrolled in my course and discussed the dual role with them prior to the end of their therapy (unrelated to my course). This was really helpful and both had good questions/agreed to the process that I go by in my class with grading and evaluations. I have not run into any problems with this yet, but do try to avoid it when I can (e.g., I try not to take patients who are enrolled in the minor i teach for, but sometimes this is unavoidable given geography/what I specialize in). I have also made this more clear with the head of our minor in terms of my ethical standards.
With that all being said, it is not ideal and is uncomfortable at times. You have to set clear boundaries ("I will not discuss matters of the course in therapy and I will not discuss therapy if you come up to me after class or come into office hours") and be very frank about how grading works. I was also really clear to document in therapy notes when we discussed these concerns prior to class starting/that the patient agreed and understood, etc..

I am still learning on this too and am definitely curious to hear other perspectives/thoughts! The dual-role piece is a huge struggle in my location (small state, college town, basically 1/10 of the state population is in a 20-mile radius with little behavioral health outside of the area). It's always discussed with my patients in some capacity, just depends on the patient.

 

[foreverbull]

This goes to show you that some of us operate under the assumption that the situation should be avoided altogether vs. the practical reality that it isn’t feasible in some cases due to communities and logistics!

If unavoidable, I agree with what’s been said about talking generally with higher ups about the situation without identifying the student, documenting all interactions/consults, consulting with an ethics person, and setting boundaries and expectations with the student.

I like this blind grading idea and/or having another instructor blind grade the student’s assignments via a rubric.....the latter option particularly shields you from student complaints of bias in the rare event that the student is disgruntled for any reason.

Final suggestion, maybe obvious, but make sure your syllabus and assignment rubrics are crystal clear and explicit about every assignment and all possible points a student can earn in the course (including late policies, attendance, etc.). There would be little to argue if a student was disgruntled if your course/assignment policies and rubrics are clearly laid out plus the blind grading mechanism (by yourself or another instructor).

 

[erg923]

I would hesitate to suggest that the student should automatically be the one to retreat from this just because of the circumstance.
It may be the only good/feasible time for them to get their education, graduate with that last class, etc. And, there is no more reason for them to withdraw from the situation than for me to do the same, right? I would assume we both have a financial stake in the issue?

Discussion of the individual issue/circumstance is warranted. Holding up someones education because of this is not warranted in most imaginable circumstances though. We landed on the Moon for goodness sake. I'm sure we can figure out something here.

 

[ClinicalABA]

From the APA ethics code:

“A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.”

It is good practice to be conservative with such matters, but I do not think this necessarily falls into the category of “reasonably expected to cause impairment etc.” Be sure to have well stated, objective grading criteria (good practice anyway). If there is anything more subjective (and there really shouldn’t be) seek out a blind reader. Acknowledge the situation ahead of time with the department head (protecting PHI, of course).