Ethical question

[LadyHalcyon]

A situation arose with a client the other day and everyone in my office seems to have a different opinion on it. Ultimately, since I am not yet independently licensed, I will do what my supervisor says. That being said, I'm curious to hear of others opinions.

During 2nd session with client she disclosed to me that, as a child, she was sexually abused by her older brothers. Charges were never filed and, according to her, her parents downplayed the situation. Client has a minor child and shares legal and physical custody with her parents. Client's older brother lives next door to her parents and she recently discovered that her child has been occasionally spending the night at her brother's house, even though her parents agreed that wouldn't happen. Her brother has two minor children (teens) and is also around minor children on a regular basis due to his job. Would you report or no? Also, the state I'm in doesn't require reporting of past child abuse if the person is now an adult.

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[WisNeuro]

A situation arose with a client the other day and everyone in my office seems to have a different opinion on it. Ultimately, since I am not yet independently licensed, I will do what my supervisor says. That being said, I'm curious to hear of others opinions.

During 2nd session with client she disclosed to me that, as a child, she was sexually abused by her older brothers. Charges were never filed and, according to her, her parents downplayed the situation. Client has a minor child and shares legal and physical custody with her parents. Client's older brother lives next door to her parents and she recently discovered that her child has been occasionally spending the night at her brother's house, even though her parents agreed that wouldn't happen. Her brother has two minor children (teens) and is also around minor children on a regular basis due to his job. Would you report or no? Also, the state I'm in doesn't require reporting of past child abuse if the person is now an adult.

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Yes this is a clearly reportable instance. Also, double check your state laws, the vast majority stipulate that if the abuse occurred while the person was a child and/or the perpetrator is in contact with children it is reportable. I don't see how there are many other opinions on this one. This is one of the more clear reporting situations I can think of.

 

[Groupthink]

Just because a state does not require reporting does not mean that you shouldn't report. As an ethical question, our mandate is to help and protect our patients. We have clear evidence of potential risk that in other states would be a requirement to report.

This becomes an ethical question of "which is more valuable: protecting client confidentiality or protecting the well-being of client and their family?"

In this case, well-being outweighs confidentiality.

My recommendation would be to first consult with a legal group and document this before taking action, given that it is not a requirement in your state. That way, you have a backup opinion. Hopefully your organization has a General Counsel group or something akin to that. Then discuss the dilemma with the patient. Depending on the circumstances, it can become empowering and therapeutic for a client to join in on making such a report, especially if they have such a trauma history. (it can also backfire, but that's patient-specific)

 

[LadyHalcyon]

Yes this is a clearly reportable instance. Also, double check your state laws, the vast majority stipulate that if the abuse occurred while the person was a child and/or the perpetrator is in contact with children it is reportable. I don't see how there are many other opinions on this one. This is one of the more clear reporting situations I can think of.

That was my reaction so I was very confused when I was met with resistance

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[LadyHalcyon]

Just because a state does not require reporting does not mean that you shouldn't report. As an ethical question, our mandate is to help and protect our patients. We have clear evidence of potential risk that in other states would be a requirement to report.

This becomes an ethical question of "which is more valuable: protecting client confidentiality or protecting the well-being of client and their family?"

In this case, well-being outweighs confidentiality.

My recommendation would be to first consult with a legal group and document this before taking action, given that it is not a requirement in your state. That way, you have a backup opinion. Hopefully your organization has a General Counsel group or something akin to that. Then discuss the dilemma with the patient. Depending on the circumstances, it can become empowering and therapeutic for a client to join in on making such a report, especially if they have such a trauma history. (it can also backfire, but that's patient-specific)

Thank you for your perspective and advice. I will look into this a little more and see if we have something like a general counsel group.

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[singasongofjoy]

Absolutely report. I’m shocked there were differing opinions, maybe the info wasn’t presented as clearly as you did in the message above?

 

[LadyHalcyon]

Absolutely report. I’m shocked there were differing opinions, maybe the info wasn’t presented as clearly as you did in the message above?

Oh no, it was. Actually two other people at the practice have prior therapeutic relationships with the client and were aware of this. I'm thinking that may be playing a role in regards to their reactions. There also was this weird "but cps won't do anything with that information" argument. It's especially tricky bc client doesn't want me to report and was like "but two other therapists here no and they didn't report."

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[PsyDr]

Ignore the ethics for a minute.

On one side you can expend maybe 10 minutes of effort, and if you are wrong you are legally protected from consequences.

On the other side, you can save 10 minutes of effort, do nothing, and risk losing the benefits of 4 years of undergrad, 5-7 years of grad, 1-2 of post doc, and all future earnings.

 

[LadyHalcyon]

Ignore the ethics for a minute.

On one side you can expend maybe 10 minutes of effort, and if you are wrong you are legally protected from consequences.

On the other side, you can save 10 minutes of effort, do nothing, and risk losing the benefits of 4 years of undergrad, 5-7 years of grad, 1-2 of post doc, and all future earnings.

Very excellent point. I've worked way too damn hard and that ain't happening. Also, if I were to find out a couple years down the road that the child was being abused and I didn't do anything....

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[temppsych123]

yeah, that sounds definitely reportable. you have reasonable evidence to suggest that there are minors who are currently at risk of being abused. this evidence can often look like specific reports from minor children about abuse, or reports from adults about abuse towards people who are currently minors, but even without those things, there's more than enough evidence to justify reporting.

Unfortunately, the behavior of the previous therapists does put you in a pretty uncomfortable situation dealing with the potential therapeutic rupture of having to make this report and then addressing it with your adult client, but I think that can certainly be validated and addressed directly with that person, and that in-and-of-itself isn't a reason not to report. I also think your gut hunch of others who should have reported but didn't now coming up with justifications for not reporting is probably accurate (I mean, yes, sometimes CPS or your state equivalent doesn't do anything, and that sucks, but that's not at all related to your obligations as a professional). If your supervisor does not come down on your side, I might remind that supervisor that, regardless of what any other therapists did or didn't do in the past, it is *their* license on the line now and that will, hopefully, move them in the right direction...

in my state, the parents of your client (e.g. current minor children's grandparents) would also be reportable for neglect on the basis that they knew the brother was a risk to his own children, and the client's child (over whom they have shared legal custody! and thus an obligation to protect!), and not only did not report him to the authorities (then or now), but continue to allow him unsupervised contact with a child in their care. bad, bad juju. That aspect of reporting, at least, might not be as difficult for the client to understand given that it sounds like that information (that the grandparents were sending the child to the brother's house for overnights unsupervised) is new to the client as well.

Good luck, OP...

 

[Sanman]

Check and see if your state board/ psych association has an ethics hotline/ consultation service. It is usually anonymous and can help to clarify issues as well as document that you made appropriate consultations with regards to ethics. Whatever is decided, document that you discussed the situation. As you stated, the final decision will be on the part of your supervisor as it is his/her license. If it were me, I would make the ethics consultation at minimum. I would likely report it to CPS also. It is the job of CPS to sort out the details of the cases that are reported in good faith. Err on the side of protecting an innocent child, IMO.

 

[LadyHalcyon]

yeah, that sounds definitely reportable. you have reasonable evidence to suggest that there are minors who are currently at risk of being abused. this evidence can often look like specific reports from minor children about abuse, or reports from adults about abuse towards people who are currently minors, but even without those things, there's more than enough evidence to justify reporting.

Unfortunately, the behavior of the previous therapists does put you in a pretty uncomfortable situation dealing with the potential therapeutic rupture of having to make this report and then addressing it with your adult client, but I think that can certainly be validated and addressed directly with that person, and that in-and-of-itself isn't a reason not to report. I also think your gut hunch of others who should have reported but didn't now coming up with justifications for not reporting is probably accurate (I mean, yes, sometimes CPS or your state equivalent doesn't do anything, and that sucks, but that's not at all related to your obligations as a professional). If your supervisor does not come down on your side, I might remind that supervisor that, regardless of what any other therapists did or didn't do in the past, it is *their* license on the line now and that will, hopefully, move them in the right direction...

in my state, the parents of your client (e.g. current minor children's grandparents) would also be reportable for neglect on the basis that they knew the brother was a risk to his own children, and the client's child (over whom they have shared legal custody! and thus an obligation to protect!), and not only did not report him to the authorities (then or now), but continue to allow him unsupervised contact with a child in their care. bad, bad juju. That aspect of reporting, at least, might not be as difficult for the client to understand given that it sounds like that information (that the grandparents were sending the child to the brother's house for overnights unsupervised) is new to the client as well.

Good luck, OP...

Fortunately my supervisor and I are on the same page, so that makes it a lot easier. Hopefully the client is willing to work through this issue but we do not have a strong therapeutic relationship right now as I have only met her twice. Thanks for your perspective.

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[LadyHalcyon]

Check and see if your state board/ psych association has an ethics hotline/ consultation service. It is usually anonymous and can help to clarify issues as well as document that you made appropriate consultations with regards to ethics. Whatever is decided, document that you discussed the situation. As you stated, the final decision will be on the part of your supervisor as it is his/her license. If it were me, I would make the ethics consultation at minimum. I would likely report it to CPS also. It is the job of CPS to sort out the details of the cases that are reported in good faith. Err on the side of protecting an innocent child, IMO.

That's a great idea. Thanks!

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[AbnormalPsych]

Report! This individual is around other young children. That is mandatory reporting everywhere I have ever been. Regardless of the past abuse to your patient (separate issue, appears not mandatory).

That being said, I don't know your state law. Check that carefully.

 

[Justanothergrad]

Consult consult consult

Document document document

 

[psychRA]

I agree that reporting is the clear answer in terms of managing liability.

With that being said, I think it's important to acknowledge the reality for the client: she's an adult who does not wish for her abuse to be reported. Her confidentiality is about to be broken, not for her own benefit but for the benefit of other people who might (or might not) be victims of this abuse. This experience may be very disempowering for her - someone else is going to share her story on her behalf without her permission. Her family will likely become aware that a report was filed, and they may behave badly towards her as a result. This experience may discourage her from talking about her abuse in the future.

None of this changes the course of action in terms of liability, but risk management doesn't cancel out or invalidate the negative impact this may have on the client. I just want to suggest that we're doing a disservice to the client if we don't recognize that.

 

[BuckeyeLove]

Had a VERY similar situation my internship year. Woman disclosed sexual abuse by stepdad that occurred when she was a young child. After it allegedly occurred, she told mom. Mom didn't believe her, so subsequently it was never reported (and also created, as you could imagine, horrible dynamics between her and mom). She then moved away for school and work. She had just moved home and in with her mother and the alleged perpetrator due to financial stress, but had a child now. So...kid was living in the home with her, mom, and the alleged perp. I asked my supervisor what to do, and she said, and I quote, "No, don't worry. That's not reportable I would say."

 

[LadyHalcyon]

Had a VERY similar situation my internship year. Woman disclosed sexual abuse by stepdad that occurred when she was a young child. After it allegedly occurred, she told mom. Mom didn't believe her, so subsequently it was never reported (and also created, as you could imagine, horrible dynamics between her and mom). She then moved away for school and work. She had just moved home and in with her mother and the alleged perpetrator due to financial stress, but had a child now. So...kid was living in the home with her, mom, and the alleged perp. I asked my supervisor what to do, and she said, and I quote, "No, don't worry. That's not reportable I would say."

It's like I am taking crazy pills. I am feeling increasingly more conflicted about it, especially bc my supervisor is basically telling me she is fine if I choose to report it and fine if I choose not to report it. Plus, client does not want me to report it. I'm just hoping during our next session she will be open to making the call herself.

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[psychRA]

Had a VERY similar situation my internship year. Woman disclosed sexual abuse by stepdad that occurred when she was a young child. After it allegedly occurred, she told mom. Mom didn't believe her, so subsequently it was never reported (and also created, as you could imagine, horrible dynamics between her and mom). She then moved away for school and work. She had just moved home and in with her mother and the alleged perpetrator due to financial stress, but had a child now. So...kid was living in the home with her, mom, and the alleged perp. I asked my supervisor what to do, and she said, and I quote, "No, don't worry. That's not reportable I would say."

I think a key difference in that situation (at least for me) is that the child's guardian (your client) is aware of the fact that the child is living with a perpetrator, and the guardian is presumably being vigilant about protecting that child. It's still a terrible situation in which there is concern for abuse, but it differs from the original situation in which a known perpetrator is working with children in a setting where no one is aware of the risk.

My sense from my grad school supervisors is that in the last 10-15 years, case law has really changed the thinking around this type of situation. I believe that prior to those lawsuits, we wouldn't have necessarily reported in situations like these unless we had a more specific reason to suspect that the original perpetrator was still harming children.

 

[boomshakalaka]

I think a key difference in that situation (at least for me) is that the child's guardian (your client) is aware of the fact that the child is living with a perpetrator, and the guardian is presumably being vigilant about protecting that child. It's still a terrible situation in which there is concern for abuse, but it differs from the original situation in which a known perpetrator is working with children in a setting where no one is aware of the risk.

My sense from my grad school supervisors is that in the last 10-15 years, case law has really changed the thinking around this type of situation. I believe that prior to those lawsuits, we wouldn't have necessarily reported in situations like these unless we had a more specific reason to suspect that the original perpetrator was still harming children.

This isn’t correct. It isn’t up to the guardian to be vigilant nor is it the duty of the clinician to be a detective. I think most language would say that having any sort of reasonable suscipion is enough to make a report or at a minimum, a consultation with the reporting line.

 

[temppsych123]

I'm of the opinion that bad practice by other psychologists and/or mental health professionals does not excuse our own bad practice. If everything you know about ethics is saying "report", and whomever you consult with (the reporting agency, your liability insurer, the relevant statute in your state) says "report", you report, even if other people made bad calls before. It sucks that this is so scattershot (the whole point of mandatory reporting is that it's MANDATORY!) but that is not your fault. Your obligations are a) follow your ethical code and state/federal regulations and b) do what you can to minimize or address the negative consequences this can/will have on your client. I'm sorry you're stuck in such a cruddy situation!

 

[LadyHalcyon]

I'm of the opinion that bad practice by other psychologists and/or mental health professionals does not excuse our own bad practice. If everything you know about ethics is saying "report", and whomever you consult with (the reporting agency, your liability insurer, the relevant statute in your state) says "report", you report, even if other people made bad calls before. It sucks that this is so scattershot (the whole point of mandatory reporting is that it's MANDATORY!) but that is not your fault. Your obligations are a) follow your ethical code and state/federal regulations and b) do what you can to minimize or address the negative consequences this can/will have on your client. I'm sorry you're stuck in such a cruddy situation!

Thank you for this comment. It's definitely not an ideal situation but you are right, I need to follow my own personal ethics and the ethics set forth by APA.

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[psychRA]

This isn’t correct. It isn’t up to the guardian to be vigilant nor is it the duty of the clinician to be a detective. I think most language would say that having any sort of reasonable suscipion is enough to make a report or at a minimum, a consultation with the reporting line.

What constitutes reasonable suspicion, though? We know that the perpetrator abused the adult client many years ago. The client's child is now living in the home with the perpetrator. With only those facts and assuming there's no indication that the client's child is also being abused, it doesn't seem like we have a reasonable suspicion that abuse is occurring now. Yes, we have reasons to be concerned, but we'd be reporting based on the concern that past behavior is predictive of future behavior, which is not the same thing as actual suspicion that the past behavior is happening again. We'd be reporting because we want to cover our butts, not because the circumstances meet the usual threshold for reporting.

If we want to limit our liability the clear answer is to err on the side of reporting every time. But if limiting our liability is the only driving force behind reporting, this client is much less likely to sue us for not reporting. She already knows that her child is living in the home with a former perpetrator. Whereas the parents of the children at the daycare who have no idea that a former perpetrator is working with their children seem to have a much stronger argument that a therapist should have reported that a known former perpetrator is working with kids.

I think it's important to be clear with ourselves about whether we're reporting because of actual suspicions about abuse, versus reporting because we want to protect ourselves from liability. Both of those can be valid reasons for reporting, but I don't think we should automatically lump the two together.

 

[PsyDr]

What constitutes reasonable suspicion, though?.

“Reasonable” is a legal term in this instance, specifically related to negligence law. It is not to mean the colloquial usage.

Basically it means that what a person in such a position should know. In practice this means, “could someone be hired to state this should have been known?”.

Since there is ANY debate, the answer is that A (but not all) prudent person would suspect.

The law can be tricky. Words that we use everyday have very specific meanings. Sorta like how reliability means validity in legal settings.

 

[LadyHalcyon]

What constitutes reasonable suspicion, though? We know that the perpetrator abused the adult client many years ago. The client's child is now living in the home with the perpetrator. With only those facts and assuming there's no indication that the client's child is also being abused, it doesn't seem like we have a reasonable suspicion that abuse is occurring now. Yes, we have reasons to be concerned, but we'd be reporting based on the concern that past behavior is predictive of future behavior, which is not the same thing as actual suspicion that the past behavior is happening again. We'd be reporting because we want to cover our butts, not because the circumstances meet the usual threshold for reporting.

If we want to limit our liability the clear answer is to err on the side of reporting every time. But if limiting our liability is the only driving force behind reporting, this client is much less likely to sue us for not reporting. She already knows that her child is living in the home with a former perpetrator. Whereas the parents of the children at the daycare who have no idea that a former perpetrator is working with their children seem to have a much stronger argument that a therapist should have reported that a known former perpetrator is working with kids.

I think it's important to be clear with ourselves about whether we're reporting because of actual suspicions about abuse, versus reporting because we want to protect ourselves from liability. Both of those can be valid reasons for reporting, but I don't think we should automatically lump the two together.

This was the argument brought up by her past provider. There is no hard evidence to suspect abuse other than past behavior. Although, child has been "flirting" with client's new boyfriend (texting frequently, hugging and touching him often). I will say though that the child doesn't live with the perpetrator, she lives next door. There was a verbal agreement between client and her parents that her child was not to spend the night over at her brother's house. Clt recently discovered her parents were not adhering to their agreement and the child had been spending the night there.

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[MCParent]

It's like I am taking crazy pills. I am feeling increasingly more conflicted about it, especially bc my supervisor is basically telling me she is fine if I choose to report it and fine if I choose not to report it. Plus, client does not want me to report it. I'm just hoping during our next session she will be open to making the call herself.

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Does the supervisor have a supervisor (site director, whatever)? This sounds clearly like a mandated report to me. Client wishes are important, but not to the final outcome of reporting in this instance.

 

[LadyHalcyon]

Does the supervisor have a supervisor (site director, whatever)? This sounds clearly like a mandated report to me. Client wishes are important, but not to the final outcome of reporting in this instance.

No. She is a co-owner of the group private practice and one of the other owners was my client's therapist before.

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[MCParent]

No. She is a co-owner of the group private practice and one of the other owners was my client's therapist before.

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Well, you’re in basically the sh****t position ever.
The right answer is to report it and then report them. If you don’t do that I don’t think you’d be the first person ever not to. What a crap situation.
I don’t see tags on your profile; can’t tell your training stage. Your faculty should at least know the site behaves unethically and not send students there anymore.

 

[LadyHalcyon]

Well, you’re in basically the sh****t position ever.
The right answer is to report it and then report them. If you don’t do that I don’t think you’d be the first person ever not to. What a crap situation.
I don’t see tags on your profile; can’t tell your training stage. Your faculty should at least know the site behaves unethically and not send students there anymore.

I'm a postdoc and yeah, not an ideal situation!

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[temppsych123]

Ooof, yeah, I'm a postdoc as well, that is rough! If you want, you can send me a direct message with your state, I'd be happy to do some sleuthing for you in terms of resources/options. If you have your own liability insurance (through the Trust or something like that), they would almost assuredly have an advice type line you could get feedback from - which might be a good idea even if you already know the answer, insofar as it gives you something to bring back to your supervisors ("so, I checked with XYZ, and it really looks like I need to do ABC, for this reason...")

 

[LadyHalcyon]

Ooof, yeah, I'm a postdoc as well, that is rough! If you want, you can send me a direct message with your state, I'd be happy to do some sleuthing for you in terms of resources/options. If you have your own liability insurance (through the Trust or something like that), they would almost assuredly have an advice type line you could get feedback from - which might be a good idea even if you already know the answer, insofar as it gives you something to bring back to your supervisors ("so, I checked with XYZ, and it really looks like I need to do ABC, for this reason...")

Unfortunately for some reason sdn won't allow me to send you a PM

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[temppsych123]

Just sent you a message, might have been something with my privacy settings?