Case Study
Patient Demographic: Client Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Marital Difficulties Diagnosis: Obsessive-Compulsive Personality Disorder 301.4 (F 60.5)
Mental Status Exam: Mental Status Exam: The client is meticulously dressed and immaculately groomed. He frequently checks his watch and states he has owned his watch since adolescence and it “still works like new.” His speech is even, and his affect is blunted. At times, he is defensive and attempts to talk over you. He exhibits poor insight into his marital problems and is excessively preoccupied with perfectionism, structure, and order. Fam
Presenting Problem: You are a counselor working in private practice and meeting your client for the first time today. The client is here at his wife’s insistence, who has threatened divorce if he does not seek and comply with therapy. The client explains that he is swamped at work and has already lost an hour of productivity traveling to your office. He discloses that he has been married just over four years and has a daughter who is 3½. The couple dated briefly and married when the client’s wife discovered she was pregnant. The client believes that if he didn’t leave his wife a schedule and checklist, “things would never get done.” He states that they would be in “so much debt” if it weren’t for his detailed household budget. In his estimation, conflict occurs each time his wife tried to do things “her way” because “it is never the right way.” You paraphrase and clarify the client’s concerns.
Other Contexts: The client arrives with his wife for his scheduled individual session today. You have yet to meet his wife in person. Before you can obtain an accurate appraisal of the situation, you find yourself mediating a conflict that has quickly intensified. The wife has given the client an ultimatum—to either stop the “endless manipulation, control, and sharp criticism” or she will take their daughter and go live with her mother, who resides in another state. The wife states that she has shown up today in a last-ditch effort to save their marriage. The client expresses a desire to remain with his wife and daughter

Question: What are the ethical implications for seeing both the client and his wife during the scheduled therapy session with the client?
(A): An ethical violation was not committed because there is implied consent due to the client being present with his wife.
(B): An ethical violation was committed because you did not clarify the nature of your relationship with both participants at the outset of counseling.
(C): An ethical violation was committed because the client is the identified patient and has not waived his right to confidentiality.
(D): An ethical violation was not committed since safely de-escalating conflict creates an exception and allows confidentiality to be breached.

Correct Answer: An ethical violation was committed because you did not clarify the nature of your relationship with both participants at the outset of counseling.
Explanation: According to the ACA Code of Ethics (2014):“When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately. […] Counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both counselors and clients. […] Counselors explicitly explain to clients the nature of all services provided. They inform clients about issues such as, but not limited to, the following: the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services; the counselor’s qualifications, credentials, relevant experience, and approach to counseling; continuation of services upon the incapacitation or death of the counselor; the role of technology; and other pertinent information”The issue of implied consent is valid for collateral contacts and may meet minimal ethical requirements; however, without a signed informed consent delineating your role and relationship with each participant, you may encounter ethical complications. The client initially allowed contact with his wife to obtain collateral information. The wife reported that she wanted to attend couples therapy, but the client was adamant that she did not participate. This brings into question the client’s capacity to provide voluntary consent (ie, it may be given under duress and thus invalid). Since conflict de-escalation in couples therapy is standard practice, this does not create an exception. The counselor did not commit an ethical violation due to the client not waiving his right to confidentiality. The issue lies with informed consent as a whole rather than one aspect of informed consent. Confidentiality is one aspect of informed consent. Therefore, the correct answer is (D)
Competency: professional practice and ethics