Steven Walfish, Ph.D.

So you are at your office in the big city and the phone rings and it is your best referral partner, Dr. Jane Doe a Family Practice Physician, is on the line. On average she refers you two clients per week for counseling and has done so for several years. Two or three times per year you go out to lunch to discuss professional issues and the two of you have developed a warm and positive relationship. She has told several of her colleagues about the fine work that you do and they have started to refer to you as well. Dr. Does is what Walfish and Barnett (2009) have called "an Apostle" for your practice in their book, Financial Success in Mental health Practice.

She begins the call by saying, "You are the best therapist that I know. I trust you implicitly to take good care of my patients. Now I have a favor to ask of you. My husband is depressed and going through a difficult time. I would like for you to see him for treatment. Based on the work you have done with all of my other patients I know you will be a good fit for him."

So now what do you do?

In my experience physicians have a different set of ethics and sense of boundaries that most mental health professionals. Will Dr. Doe understand that you have a conflict of interest in working with her husband? (e.g., can you remain neutral if he starts talking about being unhappily married? How will you respond if he self-discloses that he has had two extra-marital affairs?) Will she become upset that you will not see him, especially considering all of the business that she has sent your way? Are you willing to risk losing her as a referral partner and professional colleague? What will she tell her colleagues now that you have let her down?

I am not not sure about the exact right answer. Ethical decision-making is rarely back and white. Here are some actions to consider taking:

  • Tell her that you will gladly see him. Dual relationships are not necessarily unethical unless they are exploitive in some manner and you see no reason why not to become his counselor.
  • Tell her that you see a conflict of interest since she is a referral partner. However, you will gladly see him as long as she does not refer you any more patients as long as you are working with him in counseling.
  • Tell her that you cannot see him because you view it as a conflict of interest. You then follow this up by saying, "I want to make sure that your husband sees an excellent therapist. If I were going into therapy this is the person that I would see" and you provide her with the name of the clinician.

The important issue is to be centered in your decision-making. Do not compromise your clinical judgment due to a countertransference reaction of being afraid to lose referrals to your practice. If you make bad clinical decisions because of financial fear it may not impact you in the short-run. However, if you do this enough times it will ruin your practice in the long-run.