Huang, whose family had moved from mainland China to the United States 15 years ago, is a 45 year-old automobile mechanic. She agreed, at the strong urging of her employer, to seek psychotherapy for difficulties that seem to affect her work performance. She has been showing up late at her job, has often phoned in sick, and frequently appears distracted. She complains to her new therapist, Dr. Jackson, of the difficulties she is having coping both with psychomotor epilepsy, which has been controlled through medication, and with her progressive diabetes, for which she is also receiving medical care.
Although she has no real experience treating people of Chinese descent or patients with chronic medical conditions such as epilepsy, Dr. Jackson begins to work with Ms. Huang. She meets with her on a regular basis for three months, but never feels that a solid working alliance is developing. After three months, Ms. Huang abruptly quits therapy. At the time, she had not paid for the last six sessions.
Two weeks later, Dr. Jackson receives a request to send Ms. Huang’s treatment records to her new therapist. Dr. Jackson notifies Ms. Huang that she will not forward the records until the bill has been paid in full.
Some time later, Dr. Jackson is notified that she is the complainee in a licensing case and that she has been sued for malpractice. The complaints allege that Dr. Jackson had been practicing outside of her areas of competence because she had received no formal education or training and had no supervised experience in treating people of Chinese descent or those with multiple serious and chronic medical diseases. The complaints also alleged that Ms. Huang had never adequately understood the nature of treatment as evidenced by the lack of any written informed consent. Finally, the complaints alleged that “holding records hostage” for payment violated Ms. Huang’s welfare and deprived her subsequent therapist of having prompt and comprehensive information necessary to Ms. Huang’s treatment.
EVALUATING CHILDREN
Ms. Cain brings her two children, ages four and six, to Dr. Durrenberger for a psychological evaluation. She reports that they have become somewhat upset during the last few months. They are having nightmares and frequently wet their beds. She suspects that the problem may have something to do with their last visit with their father, who lives in another state.
Dr. Durrenberger schedules three sessions in which he sees Ms. Cain and her two children together and three individual sessions with each of the children. As he is preparing his report, he receives a subpoena to testify in a civil suit that Ms. Cain is filing against her ex-husband. She is suing for custody of her children. During the trial, Dr. Durrenberger testifies that the children seem, on the basis of interviews and psychological tests, to have a stronger, more positive relationship with their mother. He gives his professional opinion that the children would be better off with their mother and that she should be given custody.
Mr. Cain files an ethics complaint, a civil suit, and a licensing complaint against Dr. Durrenberger. One basis of his complaint is that Dr. Durrenberger had not obtained informed consent to conduct the assessments. When Mr. and Ms. Cain had divorced two years previously, the court had granted Mr. Cain legal custody of the children but had granted Ms. Cain visitation rights. (Ms. Cain had arranged for the assessments of the children during a long summer visit.) Another basis of the complaint was that Dr. Durrenberger had made a formal recommendation regarding custody placement without making any attempt to interview or evaluate Mr. Cain. Additionally, Mr. Cain’s attorney and expert witnesses maintained that no custody recommendation could be made without interviewing both parents.
STAYING SOBER
In therapy for one year with Dr. Franks, Mr. Edwards experienced alcoholism and drank heavily for four years prior to therapy. Dr. Franks uses a psychodynamic approach but also incorporates behavioral techniques specifically designed to address the drinking problem.
Two months into therapy, when it became apparent that outpatient psychotherapy alone was not effective, Mr. Edwards agreed to attend Alcoholics Anonymous (AA) meetings as an adjunct to his therapy. During the past nine months of therapy, Mr. Edwards had generally been sober, suffering only two relapses, each time falling off the wagon for a long weekend.
Now, a year into therapy, Mr. Edwards suffers a third relapse. He comes to the session having just had several drinks. During the session, Dr. Franks and Mr. Edwards conclude that some of the troubling material that has been emerging in the therapy had led Mr. Edwards to begin drinking again. At the end of the session, Mr. Edwards feels that he has gained some additional insight into why he drank. He decides to go straight from the session to an AA meeting.
One month later, Dr. Franks is notified that he is being sued. On his way from the therapy session to the AA meeting, Mr. Edwards had run a red light and had killed a mother and her child who were crossing the street. The suit alleged that the therapist knew or should have known his patient to be dangerous since he was driving while inebriated, and should have taken steps to prevent him from driving that day, specifically, as well as until his alcoholism no longer constituted a danger to the public.
THE INTERNSHIP
Dr. Larson is an executive director and clinical chief of staff at the Golden Internship Health Maintenance Organization. For one year, he closely supervises an excellent postdoctoral intern, Dr. Marshall. The supervisee shows great potential, working with a range of patients who respond positively to her interventions. After completing her internship and becoming licensed, Dr. Marshall goes into business for herself, opening an office several blocks from Golden Internship Managed Care Organization. Before terminating her work at the organization, Dr. Larson tells Dr. Marshall that she must transfer all patients to other center therapists. All of the patients who can afford her fee schedule, however, decide to continue in therapy with Dr. Marshall at her new office. The patients who cannot afford Dr. Marshall’s fee schedule are assigned to new therapists at the center. Dr. Larson hires an attorney to take legal action against Dr. Marshall, asserting that she unethically exploited the health maintenance organization (HMO) by stealing patients and engaging in deceptive practices. He files formal complaints against her with the state licensing board, charging that she had refused to follow his supervision in regard to the patients and pointed out that he, as the clinical supervisor of this trainee, had been both clinically and legally responsible for the patients. He refuses to turn over the patients’ charts to Dr. Marshall or to certify to various associations to whom she has applied for membership that Dr. Marshall has successfully completed her postdoctoral internship.
Dr. Marshall countersues, claiming that Dr. Larson is engaging in illegal restraint of trade and not acting in the patients’ best interests. The patients, she asserts, have formed an intense transference and an effective working alliance with her; to lose their therapist would be clinically damaging and not in their best interests. She files formal complaints against Dr. Larson with the licensing board, charging that his refusal to deliver copies of the patients’ charts and to certify that she completed the internship violates ethical and professional standards.
Some of the patients sue the Golden Internship Managed Care Organization, Dr. Larson, and Dr. Marshall, charging that the conflict and the legal actions (in which their cases are put at issue without their consent) have been damaging to their therapy.
THE FATAL DISEASE
When George, a 19 year-old college student, began psychotherapy with Dr. Hightower, he told the doctor that he was suffering from a fatal disease. Two months into therapy, George felt that he trusted his therapist enough to tell her that the disease was AIDS (acquired immune deficiency syndrome).
During the next 18 months, much of the therapy focused on George’s losing battle with his illness and his preparations for the end of life. After two stays in the hospital
