Ethical Issues in Psychotherapy -
Portrayed in a Movie
by Birgit Wolz, Ph.D. and Ofer Zur, Ph.D.
Jennifer Todd, Suzanne Todd, Mark Gordon
Uma Thurman, Meryl Streep, Bryan Greenberg, Jon Abrahams, Adriana Biasi, David Younger, Aubrey Dollar
Year of Release:
Rafi Gardet, a 37-year-old recently divorced and vulnerable woman, is reluctant to believe she even deserves to be happy. Against her better judgment she becomes involved with a 23-year-old jobless handsome, masculine but gentle artist named David Bloomberg, who himself is age appropriately insecure and confused.
The complications of her romance become the main topic of conversation in her psychotherapy sessions with Dr. Lisa Metzger. Although she initially lies about David's age, pretending that he is 27, Rafi tells her therapist that she is worried about their age gap and David's demanding relationship with his overly protective Jewish mother. Because her client appears increasingly happier as her relationship develops, Metzger encourages her to seize the moment.
All is well until it dawns on Lisa Metzger that the young man in question is actually her own son. Because his age has been lied about, she had no reason to guess this earlier. Especially since she discovered this long after a strong therapeutic bond had developed with her client, the therapist is faced with an ethical dilemma of whether to disclose her realization to the client and face the significant inevitable ensuing complications.
After consulting with her own therapist/consultant, Lisa Metzger continues the sessions, during which she hears much more about the intimate aspects of the client and son's relationship than any of them would choose. Rafi talks about David's lovemaking, admirable details of his physique, even the size of his sexual organ, and his opinion of . . . his mother.
At the same time, the therapist's concerns for her son are the age difference and the fact the Rafi is not Jewish. Because Metzger believes that religion is paramount in a person's life, she urges him strongly to let go of Rafi and marry within his faith.
The film blends humor with touching gravity. The therapy is terminated with the client feeling betrayed and, subsequently, being received through the "family" door as the girlfriend of the therapist's son.
Unavoidable Simultaneous Social Dual Relationships
· Not by her own choosing, Dr. Lisa Metzger finds herself in a dual relationship and a conflict of interest as the mother of her client's boyfriend. Because she doesn't disclose this to Rafi for some time, Metzger finds herself in several difficult situations: trying to avoid David and Rafi running into each other near her home-office, trying to avoid being seen by the couple in a furniture store, and having to listen to details of her son's sex life.
· As soon as she knows about the romance between her son and her client, Metzger becomes very nervous. The therapist finds her own neurotic features leaking into the therapy and her personal needs clashing with her professional commitments. In one scene the therapist, seeing her son's middle school picture displayed, jumps up in the middle of a session to turn it face down. She terminates one session prematurely, secretly sheds some tears during the therapeutic hour, and changes her advice to Rafi completely. In contrast to her prior guidance, she now expresses doubts whether this relationship is beneficial for her client. The therapist is clearly in a conflict of interest between her role as a mother and her role as a therapist. She loses her objectivity and therefore cannot be therapeutically efficient any more.
This is an example of a very complex unavoidable and unpredictable dual relationship. While more common in small communities, such dual relationships are rather rare in big cities, such as NY. The therapist and client must face a situation that neither one of them anticipated or was prepared for. As soon as Metzger realized that her client was dating her son she appropriately sought consultation from a confident and competent consultant/therapist. Such consultation is likely not only to help her arrive at the best ethical and clinical decision but also increase the possibility that her actions are within the standard of care regarding this complex situation.
Confidentiality in Consultations
After Dr. Metzger finds out about the intimate aspects of her client and son's relationship, she shares her concerns with her own therapist turned consultant. Lisa Metzger wants to know whether she should continue treating Rafi. In one session her consultant tells Metzger that her primary job is treating her client: "That is your ethical boundary." The consultant reasons that the couple might break up after a few weeks of courtship. In that case a termination of therapy might be damaging for Rafi. Lisa Metzger gets upset about this conflict and cries. She expresses even more doubts in a subsequent meetings saying, "I am confused about my part in this." But her consultant reassures Lisa that what she was doing was ok.
Through consultations, therapists can get help in working on their own issues that may come up in the course of therapy, conduct a thorough risk-benefit analysis, get help with constructing a treatment plan, dealing with difficult situations and difficult clients. Consultations can also help therapists practice within the standard of care. The proper use of consultations is depicted well in this movie. Therapists have generally two choices in regard to confidentiality when discussing cases with their consultants. They can either get permission to discuss their cases at the outset of therapy or at any time afterward or make sure that the patients' identity is concealed and all identifying details are not presented in the consultation.
Self-Disclosure As Part of a Home-Office Setting
Dr. Metzger's office can be reached through a door right next to the entrance that leads to her living quarters. In one scene, her son walks out of the front door, carefully timing his exit from 'home' because his mother tells him a client is arriving at the 'office'. The therapist looses track of time and the two narrowly miss running into one another as home and office almost collide.
The home-office setting creates a situation where significant self-disclosure is inevitable. Rafi, like all other clients, is instantly aware of where her therapist lives, the price range of her residence, the socio-cultural aspects of her neighborhood, the style of furniture and décor, and they may bump into family members, pets or other people who reside or visit the residence.
Incidental Encounters and Confidentiality
Dr. Metzger bumps into her client in a department store. As she sees her son and her patient in the store she abruptly pulls her husband behind a bed trying to avoid to be seen by Rafi and David. Because her husband wants to know what is going on she discloses the nature of her relationship with Rafi.
Incidental, chance or unplanned encounters between therapists and clients often bring up the concern of confidentiality. If the therapist acknowledges the client in public first, that may expose the therapeutic relationship to others. Of course, it is the client's right to expose the therapeutic relationship if they choose to. In this case exposing the fact that Rafi was in therapy with Dr. Metzger was part of the unavoidable complexities that transpire from the unpredictable dual relationships that the doctor found herself in. Sometimes there are situations where therapists must weight their options, analyze the risks and benefits of each action and in-action and come up with a course of action that is likely to be either most beneficial or less harming to the client. In this difficult and surprising situation Dr. Metzger seemed to assess that not exposing her patient and son to the fact that she is the therapist and a mother was quit reasonable.
When therapists realize that chance encounters are likely, they should discuss with their clients how they prefer to handle it. While some clients are happy to acknowledge the clinical relationships, others prefer to keep more private. When possible and appropriate, it is better for therapists to take the cue from the clients when they meet accidentally in public places. While therapists should do their best to protect the privacy of the clinical relationships, sometimes this is not possible. It is also advised to not only discuss the issue with clients, when appropriate, ahead of time, but also after such encounters. Research has pointed out that many clients are not as concerned with incidental encounters as therapists are. It also has revealed that sometimes when therapists do not acknowledge clients in public places, it can make the clinical relationships more transparent and/or harm the clinical relationships if the client interrelates it as a rejection or non-caring.
Disclosing Confidential Information
When Dr. Metzger tells her son that she knows about his romance and that Rafi is her client, she also discloses some of the content of their therapy sessions with him.
Again, this is a very complex case of dual relationships and confidentiality. Dr. Metzger should have either obtained an authorization to release information from Rafi before she spoke to her son or not disclosing any confidential information. Not doing so is unethical.
Unavoidable Sequential Social Dual Relationships
After Metzger and Rafi discontinue therapy, and against his mother's initial resistance, David brings his girlfriend home for a family dinner. The therapist and her ex-client tell each other that they missed each other. Rafi gets to know her ex-therapist's husband, parents, and parents in law. To welcome her and thank her for a present, Lisa gives her ex-client a welcome kiss. Rafi observes her therapist now in the roles of the woman of the house, a cook with an apron, and a host. Lisa and Rafi sit next to each other at the dinner table and talk to each other as they clean up together after dinner. When the tension between them reaches a peak, Rafi tells Lisa Metzger how "very strange" this new situation is for her, while Metzger pretends that she doesn't have any problems with the visit.
Once the therapeutic relationship ended, Metzger and Rafi continue to be in relationship through David. This is an unavoidable sequential dual relationship, as Metzger does not have a say whether her son and ex-patient continue to date each other or not. Both therapist and client clearly and appropriately acknowledge the awkwardness of the situation.
Birgit Wolz wrote the following continuing education online courses:
Cinema Therapy - Using the Power of Movies In the Therapeutic Process, which guides the reader through the basic principles of Cinema Therapy.
Cinema Therapy with Children and Adolescents - This course teaches Cinema Therapy with young clients. It includes numerous movie suggestions, which are categorized according to age and issues. It serves therapists, teachers, and parents.
Positive Psychology and the Movies: Transformational Effects of Movies through Positive Cinema Therapy - This course teaches how to develop clinical interventions by using films effectively in combination with positive psychotherapy. It serves for mental health practitioners and anybody who is interested in personal growth and emotional healing.
Therapeutic Ethics in the Movies - What Films Can Teach Psychotherapists About Ethics and Boundaries in Therapy, which covers: confidentiality, self-disclosure, touch, dual relationships and out-of-office experiences (i.e., home visits, in-vivo exposures, attending a wedding, incidental encounters, etc.)
Boundaries and the Movies - Learning about Therapeutic Boundaries through the Movies, which covers informed consent, gifts, home office, clothing, language, humor and silence, proximity and distance between therapist and client, and, finally, sexual relations between therapist and client.
DSM: Diagnoses Seen in Movies - Using Movies to Understand Common DSM Diagnoses.
Psychodynamic Diagnostic Manual (PDM) - A New Approach to Diagnosis in Psychotherapy