The 3.12(e) Violation

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Ines’ supervisor talks to her about how this situation came to be. Ines explains that she had been seeing a 15-year-old girl who was referred by several other teenaged girls in her school with whom Ines had worked successfully within the areas of body image, self-esteem, and weight loss. This young girl’s mother discovered that her daughter had begun some very risky dieting procedures, including purging by use of vomiting and laxatives, taking diuretics, and an extreme exercise regimen that resulted in a drastic 20 pound loss in a short period of time. Consequently, when the mother confronted the daughter about these concerning behaviors, the girl became enraged at her, and reported that her therapist was a specialist at health and weight loss, and that she gave her these ideas and supported her efforts. At first, Ines adamantly denied the young client’s claims, but after breaking things down with her supervisor, she realized that perhaps there were ways she could have been more careful and transparent in her practice.

So how did a well-intentioned clinician in good standing at her agency, end up being investigated for professional misconduct? She reported that she “meant well,” and that her intent was “to treat this client with ethically-sound interventions that had been quite successful with other teenage girls who presented with similar issues.” She saw no egregious misconduct in her behaviors. However, the state felt differently about things. The following contains a short discussion of a number of possible violations Ines may have been teetering on in her treatment. Consider your thoughts on each, and whether you feel Ines was in violation or not. More importantly, what could Ines, or any therapist, do differently going forward to avoid this scenario in clinical practice?

1.2 Informed consent

Marriage and family therapists obtain appropriate informed consent to therapy or related procedures and use language that is reasonably understandable to clients. When persons, due to age or mental status, are legally incapable of giving informed consent, marriage and family therapists obtain informed permission from a legally authorized person, if such substitute consent is legally permissible. The content of informed consent may vary depending upon the client and treatment plan; however, informed consent generally necessitates that the client: a) has the capacity to consent, b) has been adequately informed of significant information concerning treatment processes and procedures, c) has been adequately informed of potential risks and benefits of treatments for which generally recognized standards do not yet exist, d) has freely and without undue influence expressed consent, and e) has provided consent that is appropriately documented.

Without seeing Ines’ informed consent, it is impossible to gauge whether or not she adequately detailed the type of treatment she was offering this client and her parent, as the client was a minor at the time of treatment. Full disclosure of her treatment protocol and methods would have helped everyone involved be aware of treatment types and intentions.

3.10 Scope of competence

Marriage and family therapists do not diagnose, treat, or advise on problems outside the recognized boundaries of their competencies.

Is such specific treatment for weight and nutrition issues within the scope of experience of this therapist? If so, has she advertised it as such? Does Ines have special training, expertise, or ample experience in this topic area? Is she able to manage the physiological aspect of this issue, or does she need to be coordinating care for this client via collaboration with a medical doctor or nutritionist?

9.1 Accurate professional representation

Marriage and family therapists accurately represent their competencies, education, training, and experience relevant to their practice of marriage and family therapy in accordance with applicable law.

After Ines’ client’s mother made the complaint that she was misrepresenting her abilities, Ines realized that a coaching business she had many years before still showed up when someone Googled her name, along with a number of articles and blogs the clinician had written on wellness and weight loss for a variety of sites. Ines also recalled referencing her experience in coaching on several occasions to her client. Could this easily accessible information mislead the client to believe that the therapist was much more an expert in this area than she really was?

9.7 Specialization

Marriage and family therapists represent themselves as providing specialized services only after taking reasonable steps to ensure the competence of their work and to protect clients, supervisees, and others from harm.

Did Ines take her “expertise” too far in designing work out plans, caloric intake limits, food choices, and meal preparation with her client? Was it appropriate for the client to share daily weigh-ins with the therapist to be “accountable” to her for her efforts and success towards the client’s goal? If Ines truly had the experience and knowledge to appropriately integrate the health and weight coaching into her treatment of the client, perhaps she should have included explicit information regarding this in her informed consent? The Ethic’s concept of “autonomy” means that clients have the rights to make their own informed decisions on things. Perhaps Ines could have avoided this whole issue by simply stating to the mother and the (minor) client at the beginning of treatment something like this:

“I have worked with many young women with similar issues, and I have found success in these girls achieving their goals by applying a number of strategies to their treatment. In addition to (insert preferred model of therapy here), I often include such interventions as journaling, creating an exercise and eating plan with the client, and daily check-ins on how the client feels they are doing with therapeutic homework, etc. during the time between sessions. I encourage you both to talk about how things are going, and to let me know if these methods seem to be problematic or concerning in any way.”

In this way, Ines would have been completely transparent in what she intended to offer, and the client and her mother could make an autonomous and informed decision based on this full disclosure.

1.3 Multiple relationships

Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken.

Do you think Ines’ role as therapist might have been confused by the client (or the client’s mother) as a coach, a doctor, a weight loss specialist, a friend, a mother?

The AAMFT Code of Ethics, Standard III, Professional Competence and Integrity, states:

3.12 Professional misconduct

Marriage and family therapists may be in violation of this Code and subject to termination of membership or other appropriate action if they: a) are convicted of any felony, b) are convicted of a misdemeanor related to their qualifications or functions, c) engage in conduct which could lead to conviction of a felony, or a misdemeanor related to their qualifications or functions, d) are expelled from or disciplined by other professional organizations, e) have their licenses or certificates suspended or revoked or are otherwise disciplined by regulatory bodies, f) continue to practice marriage and family therapy while no longer competent to do so because they are impaired by physical or mental causes or the abuse of alcohol or other substances, or g) fail to cooperate with the Association at any point from the inception of an ethical complaint through the completion of all proceedings regarding that complaint.

The vast majority of the cases that are deliberated by the AAMFT Ethics Committee are found to be in violation of 3.12(e). Specifically, these cases include members who had been sanctioned by the state in which they practice and had their licenses suspended or revoked. Regardless of what other AAMFT Code violations (for example, the sub standards listed underneath the aforementioned case scenario) may have occurred by the member, the Committee will first file the 3.12(e).

There are many reasons that a member can be sanctioned by the state. Most complainants first make reports to the state’s licensing board or department of health because they may not know about the professional body that governs MFTs. In the state of New York, for example, professional misconduct violations can include being convicted of a crime, physical or sexual abuse of another person, practicing under the influence of alcohol or drugs, refusing a client service because of race, creed, color, or national origin, or aiding an unlicensed person to perform activities requiring a license (NYSED.org, 2019).

States vary widely on the range of sanctions they can impose on practitioners. On the Ethics Committee, we have seen states mandate attendance at workshops to obtain CEUs in areas of incompetence, appoint monetary fines, or refer to special programs for alcohol or drug addiction. In egregious cases of misconduct, or when direct harm has been inflicted upon a client, the state may choose to suspend a therapist’s license for a period of time, or to revoke it permanently.

So, how can AAMFT members best protect themselves from being accused of professional misconduct that may result in a retraction of their licenses to practice, and perhaps subsequently result in a 3.12(e) violation through the Ethics Committee? The following is a simple overview of checks and balances that every practicing MFT should revisit on a regular basis:

Read through the AAMFT Code of Ethics annually, and be familiar with the tenets it contains.

As a graduate professor who teaches the Ethics course every spring, I am fortunate for the yearly reminder and overview of our Code. However, for therapists who are not in academia, the “fine print” of the Code, especially in an area that a clinician may not encounter often (such as non-abandonment when experiencing illness, or a sudden need to close a practice), can fade into simple background noise.

Make time to visit the AAMFT website

The site contains links to every issue of Family Therapy magazine (FTM), tips for maintaining an ethical practice, legal and ethics fact sheets, and articles on various topic areas to help members best stay on top of an ethically-sound practice.

Workshops/trainings/CEUs

As the Ethics Committee considers appropriate sanctions for members found in violation of the Code, we often uncover a plethora of workshops and trainings that spans a wide range of topic areas. Many states now require a certain number of CEUs each year to maintain licensure. Therapists should be mindful of what sorts of trainings they feel are important to their particular practice.

Talk to colleagues/supervision groups

It is easy for any of us to get “lost” in the intense work that we do in offering treatment to clients. This is even more common in the isolation of private practice. It can be incredibly helpful to get out of one’s own mind and learn through other therapists’ stories, mistakes, or methods. I often share with my graduate MFT students the importance to me of supervision and of processing cases with colleagues in my own practice. Many times, these students are surprised that very experienced therapists still “need” supervision. My reply to them is this—“Do seasoned clinicians, or any clinicians at all, really need supervision? Or is it really that they want supervision? I believe the wisdom is in the distinction between the two.” This is yet another helpful tool to maintaining an ethical practice.

In summary, even the most well-intentioned and seasoned therapists can make mistakes, or miss things that may be misrepresented or misconstrued by clients. The aforementioned suggestions can help therapists keep a watchful eye on their offerings, incorporate fresh and novel ideas into their treatment and techniques, and keep on top of an ethically-sound practice.