As I see it, there are three issues associated with this case. What is the therapist’s duty of care to the client? What is the therapist’s duty or obligation to the community? What is the therapist’s duty to herself?

The therapist has a duty to provide treatment that is within her scope of practice and is likely to benefit the client. On the basis of the information provided, I am not satisfied that she is discharging either duty in this case. It is unclear whether the therapist has the clinical skills, training or experience to provide treatment to a person with this kind of complex disorder. She is in receipt of supervision but it is not clear that her supervisor has any more expertise than she. I would want to be reassured that the therapist is adequately equipped to provide treatment to this kind of person. Beyond the scope of practice, even if the therapist is competent to treat the client, it is unclear whether the client is currently benefiting from treatment, or likely to benefit from treatment in the future. The therapist ‘thinks his prognosis is bleak’ which means she does not entertain any real hope for therapeutic gains. She appears to have the view that he would benefit from a different form of treatment from the treatment she is providing (although that may be simply a consequence of her own self doubt). She apparently thinks that her therapy is preventing the client from killing himself, but it is quite likely that this belief is a reflection of her feelings of responsibility towards the client, rather than because the therapy is actually preventing suicide. It is unclear whether she has had a frank discussion with the client about the value or otherwise of therapy, or whether she has seriously explored alternative means by which he could meet his needs for regular human contact, or advance his goal of further education.

It is unclear who is paying for the therapy but, given that the client is in receipt of a disability support pension, it is likely that payment is by a third party, possibly the taxpayer. In these circumstances, the therapist has a (lesser) duty to any third party to provide treatment that is cost effective and consistent with the purposes for which the funding has been made available. There is insufficient information in the case to do more than raise the issue, but there must be doubts as to whether these requirements are being met.

I have concerns that the treatment is having an adverse impact on the emotional well-being of the therapist. She appears to be struggling with an overwhelming burden of responsibility and is feeling inadequate and ineffectual. While such feelings will form part of the transient experience of any psychotherapist, in this case they appear to be persistent and unmoderated by any affection for the client, sense of achievement in the work, or hope for the future. The therapist is at risk of burnout and this is a matter of concern: in the first instance, because it is an avoidable harm to her; and, in the second instance, because it is likely impair her capacity to work effectively with other clients.

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Correspondence to Robert King.

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King, R. Response. Bioethical Inquiry 8, 99 (2011).

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  • Public Health
  • Adverse Impact
  • Clinical Skill
  • Insufficient Information
  • Complex Disorder