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Monday, February 11, 2013

Vignette 22: A Duty to Report?

Dr. Tell worked with a woman for several months on issues related to depression, anxiety, and relationship issues. During one session, the patient indicated that her boyfriend has lost interest in sex and became more involved with online pornography. While discussing these issues, the patient suddenly stopped talking. Dr. Tell allowed several moments to pass before asking the patient what was happening. 

The client indicated that she was hesitant to speak about the issue for fear of a breach of confidentiality. Dr. Tell reminded her about confidentiality and the laws in Pennsylvania that would override it. The client continued to struggle. She eventually blurted out that, during a heated discussion, her boyfriend indicated that looking at online pornography was not as bad as what his uncle did. She went on to detail how her boyfriend described how his uncle was involved in collecting and distributing child pornography but remained faithful to his aunt. The client's boyfriend expressed that she should never discuss this with anyone. The client asked if she could just give Dr. Tell the information about the uncle so that she could report it to the authorities and leave her out of the situation. The client is feeling very helpless and vulnerable about this bind. 

Dr. Tell explained that the alleged perpetrator was several times removed from their sessions and she did not believe that she had the obligation to report it. The client then asked if she could invite her boyfriend to the next session so that they could all discuss the information and the best way to handle the situation. 
Dr. Tell focused the client on her dilemma as well as the relationship issues with her boyfriend. Dr. Tell agreed to contact someone to discuss whether Dr. Tell had to report this information to the police or Child Protective Services. And, Dr. Tell agreed to determine whether or not reporting this information would put her client’s confidentiality at risk. She also agreed to think about the need to bring in the boyfriend, because inviting him to therapy will not necessarily help the situation.
Dr. Tell contacts you with the above scenario.
1. How would you feel if you were Dr. Tell?
2. How would you feel if you were the consultant?

3. Is Dr. Tell a mandated reporter in this situation?

4. As a mandated reporter, would Dr. Tell report place her client's confidentiality be at risk?
5. If Dr. Tell is not a mandated reporter, should Dr. Tell bring in the boyfriend gather more facts so that Dr. Tell can report the alleged crime?
6. Is the goal of therapy to help the client manage the situation or is the responsibility now on the psychologist to gather more information about the possible crimes committed with children?
7. Can the client contact Child Protective Services anonymously in this case?

8. Can the psychologist contact Child Protective Services anonymously, provided that the client supply the name and address of the uncle?

9.What should the psychologist do?


grschoener said...

I will try to comment in more detail, but reporting duties vary considerably state to state. In the case of Wisconsin, this is not a mandate. In the case of Minnesota it might be. Reporting questions are not typically generic.

Gary Schoener

TG said...

In PA, this is not a mandated report. The wording is clear that the child about whom one suspects abuse must be before you in your work. While there are unidentified victims here, Dr. Tell is not even seeing the offender professionally. Not even a duty to warn situation.

I would suggest the problem in the therapy is the relationship between Dr. Tell and the client, the latter wanting help with a dilemma in her life: living with the knowledge of an identifiable offender and how to deal with that knowledge in good conscience. In other words, the ethical situation is the client's not the therapist's.

Dr. Tell does not help the client by making a report to authorities. Yes, Dr. Tell may well be upset that there is an identified offender out there (boyfriend's uncle). Of course she is. But breaking confidentiality and playing an inappropriate role to quell her discomfort is wrong both ethically and from a therapeutic standpoint as well.

With the Dr.'s help, the client can be encouraged to explore her feelings about her knowledge. The Dr. can help the client decide what course of action on her part would be best. Not forgetting that she has a problem with her boyfriend and his involvement with porn, there a lot of meat here for therapy. The uncle info feels like a distraction to me. My advice is stay with therapy and don't be distracted with reporting. It's not a mandate and it would be going outside of professional role to make any kind of report.

Dav id Herman said...

Dear Colleagues,

I begin my response by observing the number of questions the author of the vignette suggested be answered. They seem to follow a decision making procedure, so the structure is helpful. On an emotional level, I think they probably reflect the ambivalence and anxiety that would likely be induced when presented with such a situation as a practitioner.

I would feel curious about how to study the complicated communication presented by the client. I believe it is important to note that the client presented a detailed, complex set of requests of the therapist, indicating organization and planning. She also expressed ambivalence about taking responsibility for acting on a potential need to report illegal activity allegedly perpetrated by the client's partner's uncle. The indirectness of the communication seems to be significant and may reflect the client's overall approach to problem solving.

As the consultant, I'd be interested in helping, though in addition to studying the facts, I find the style of the client irritating, which suggests that she is expressing her own anger indirectly in a way that induces such a response in others.

According to the PA Code for Board regulated practitioners, the duty to report is defined as:

Board regulated practitioners who, in the course of their employment, occupation or practice of their profession, come into contact with children shall report or cause a report to be …

If Dr. Tell were a mandated reporter, then she would be required to notify the client that confidentiality would be breached in complying with the professional duty to report suspected child abuse or neglect.

5. If Dr. Tell is not a mandated reporter, should Dr. Tell bring in the boyfriend gather more facts so that Dr. Tell can report the alleged crime?

The language in the code quoted above states taht reporting is required when the professional has direct contact with a child. As Dr. Tell is not treating the child, it seems logical that the duty to report would not accrue to her.

6. Is the goal of therapy to help the client manage the situation or is the responsibility now on the psychologist to gather more information about the possible crimes committed with children?

The goal of the therapy is to support the client in responding to the situation. It is the duty of law enforcement officials to gather information about possible crimes. The threshhold for mandated reporters treating children directly only requires them to have reason to suspect abuse and/or neglect, not to find evidence to prove that abusive or neglectful acts were, in fact, perpetrated.

The client can contact Child Protective Services anonymously in this or any case, as reporting may not require the disclosure of identity. However, the benefit of the disclosure of identity is that it may assist the investigators to get additional information necessary to their investigation.

The psychologist can contact CPS anonymously, whether or not the client provides identifying information for the alleged perpetrator. It seems probable that CPS will advise the psychologist whether the information would mandate an investigation on their part. As that seems not to be the case, it appears that the psychologist would be contacting CPS for feedback about the appropriateness of her/his response to information received from the client.

It seems that the most appropriate response by the psychologist is to begin a discussion about the complicated nature of the situation, to clarify the boundaries and to consult the client about alternative solutions to the problem. It is my opinion that an anonymous call to the police, to contact the Sex Crimes Unit with identifying information about the uncle might be an appropriate step for the client to take, but not the therapist.