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Thursday, May 5, 2011

Vignette 2: A Suffering Caregiver



A colleague of yours, Dr. Solomon, contacts you for advice regarding a new client she has just seen. The client, Mr. Don Tellanyone, is a 47-year-old man who is seeking services for depression. During the initial phone contact, he asked repeatedly about privacy and wanted assurances that information discussed in session was confidential. The patient repeated this line of questioning during the first face-to-face session.

As the session progressed, he revealed that the source of his depression was the death of his mother one year ago. His mother had suffered from a combination of severe respiratory problems and Alzheimer’s. Mr. Tellanyone had been caring for her and his father in his home for 6 years prior to her death.  During the last two years, she required total care. He revealed that she had been suffering greatly and, out of compassion for her, he gave her an excess dose of her sleeping and pain pills. Medical personnel never questioned the death as the woman had been quite sick and “It was only a matter of time.”

Mr. Tellanyone goes on to explain that he is now caring for his father in similar circumstances, although there is no dementia. His father has declined rapidly since the death of his wife and now requires total care. Mr. Tellanyone reveals that recently he had a conversation with his father in which the father commented how peaceful his wife’s death was and how he hoped for a similar passing.

Mr. Tellanyone is feeling quite guilty about his mother.  Simultaneously, he strongly believes he made the right decision. He would like help to work through the issues. He is also very concerned about confidentiality and wants assurances from Dr. Solomon.

Dr. Solomon, feeling uncomfortable with the situation, contacts you for a consultation about the potential ethical issues for this case.

What are the potential ethical issues in this case?

What would you advise?

5 comments:

Anonymous said...

For some reason I am unable to post a response to this vignette here. I have placed my response at my blog instead, you can reach it by clicking or C&P the following link:

http://pht-sc.blogspot.com/

~Sheila

Anonymous said...

Given the issues revealed, it is no small wonder Mr Tellanyone would be concerned about confidentiality. One thing I would hope is that Dr Solomon clearly explained its limits at the outset of treatment, ie., the possibility of records being released if a court were to order them/the indication to harm oneself or another/etc.




That said, without a requirement to report something that happened in the past, the therapist can preserve confidentiality and focus on the client's working through whatever depression/grief/guilt he presents regarding the mother’s death. When it comes to the father, however, red flags rear their wildly waving heads. Because then we are talking about the future. And while what Mr Tellanyone has presented so far is not reportable, (the client is not saying that he is planning to give his father an overdose), he does have the means (medications), the propensity (future behavior better predicted by past behavior- he has already given the mother a fatal overdose and despite feeling guilty about it, has effectively rationalized), and the emotional pull to be a danger to the father (father verbalizing the wish for a similar death without realizing he may be inviting his son to actualize it).




I think that Dr Solomon would be wise to frankly open up and explore the topic of overdosing the father as he processes the death of the mother. What direction to take that topic would be importantly related to Dr Solomon discerning the structure of Mr Tellanyone's personality organization. Is he neurotic? Psychotic? Borderline? Is he an *As if*? Determining which would indicate whether Dr Solomon should help him to uncover (discuss rescue fantasies/urges related to overdosing the father, while making it clear that doing so is unacceptable.. and reportable) or to shore up ego resources (and so avoid uncovering fantasies/urges when there are poorly regulated impulses as in the case of borderline/psychotic acting out). Optimal choice of treatment modality (analysis vs face-to-face psychodynamic ego/self psychotherapy vs CBT vs DBT) could hinge on just where Mr Tellanyone stands psychologically and in conjunction with his particular personality style and response to treatment. I would imagine promoting neutralization of aggression with a neurotic client (*it’s ok to talk about overdosing your father.. but you must not actually overdose him*) might open up other issues about Mr Tellanyone’s having overdosed the mother. This would ultimately become sensitive grist for the therapeutic mill.




In any case, no matter what Mr Tellanyone's psychological organization, I think that Dr Solomon would be wise to fully inform the client that if she has any reason to believe Mr Tellanyone would actually overdose the father, she would be obligated to breach confidentiality.

~Sheila

Anonymous said...

I would like to request permission to use this vignette as part of a group supervision exercise, with three other experienced therapists.
Harriet Kline PhD

PPA's Ethics Committee said...

Thank you for asking for permission. The answer is a definitive yes!!

Simultaneously, our goal is to help with ethics education in any way possible. So, our vignettes, our articles, and our site are geared to be a resource for psychologists to help other psychologists and psychologists-in-training with ethics and ethics education.

Feel free to direct interested psychologists, trainees, and students to our site as well.

Thanks again for your interest!!!

Anonymous said...

I did not get into as many "What ifs" or "if thens" as Sheila did (by the way, nice job Sheila) but I did say Unless the therapist can gain assurances that her patient will not harm his father, she must notify authorities as it is possible he will "do harm" to his father. It is possible that the story about his mother is false and he only wants validation that pulling a "Kavorkean" (assisted suicide w/o Dad's consent) on Dad is a rational sane thing to do, IE ...he is asking for permission to do that which he wants to do. He is clearly stressed beyond rational thought and unable to make sane decisions at this point. He is over-tired and not thinking clearly. Just in the "off" chance he is seriously considering this, Dad should be placed, at the very least, in an assisted living facility until the son can get some rest and come back to his senses. the therapist should work on his guilt, shame, stress, and anxiety, and Sheila is right, his grief issues as well. So, what's the real truth...studying for grad comps.... Laura