PROFESSIONAL ISSUES
The Ethical Practitioner-Client Relationship
Sebastian “Seb” Striefel, PhD
Department of Psychology at Utah State University, Logan, UT
Keywords: ethics, practitioner-client relations
Spring 2005 ⎪ Biofeedback
The practitioner-client relationship is an extremely
important, influential, and often critical component
of successful treatment. Care should be taken to not
take this relationship for granted; rather, practitioners should attend to the formation of this relationship with each client. Client autonomy and the practitioner-client relationship are both enhanced by
obtaining valid informed consent in a sensitive and
truthful manner. A number of other factors such as
listening, extending common courtesies, getting
client feedback, and monitoring and addressing subtle changes in affect and behavior can also be helpful in building a working relationship. A conscious
intent to do one’s best in helping a client can also be
useful. Paternalism is seldom, if ever, an acceptable
alternative to informed consent. The focus should
remain on doing what is in the best interests of the
client and that includes due consideration of client
input.
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Introduction
Practitioners should not take the practitioner-client
relationship for granted. Practitioners should carefully attend to establishing a good working relationship
with each client and should consider referring elsewhere those clients with whom they cannot establish
a good relationship. Sometimes a discussion of the
concern about a relationship that is not working can
help improve the relationship. A good practitionerclient relationship (therapeutic alliance) is needed: a)
to find the appropriate balance between building the
relationship and building skills, b) to get a client to
come to and stay in treatment, and c) to motivate the
client to participate and learn new skills.
Building the relationship can involve a wide
variety of skills and approaches. A good place to
start is by making a conscious intent to do one’s
best to help the client and to do what is in the best
interests of the client. Some other useful skills and
approaches for improving the practitioner-client
relationship include: listening, extending common
courtesies, being empathic and caring, getting
informed consent, establishing a working partnership, helping the client achieve some early success,
using mutually agreed upon homework, providing
a rationale for what you do as you do it, eliciting
client feedback regularly, varying your intervention style as needed, helping the client solve problems, alleviating distress, and monitoring affective
and behavior changes during sessions. What other
approaches do you use or could you use to improve
the practitioner-client relationship?
The Contract
The professional-client relationship is a contract, verbal or written, and is basically a voluntary agreement
between two or more parties because both expect to
achieve some benefit. For the client the benefit is
receiving a service to help with a problem, illness, or
disease. For the practitioner it is receiving an income
for the service provided so he or she can make a living. It is from this contract that the ethical and legal
rights of the client and the concomitant obligations of
the practitioner arise.
Bayles (1988) argues that the professional-client
relationship is a fiduciary (based on trust) one in
which the client must trust the practitioner, but also
one in which the client retains significant responsibility and authority (autonomy) for decisions about
what happens to him or her. There are many ethical
and legal obligations acquired by the practitioner
when entering into this special type of relationship.
They include, but are not limited to: doing no harm
(beneficence), keeping promises (fidelity), being honest, making reparations for any past injustices or
client perceived injustices (Bayles, 1988), maintaining
client confidentiality, working for and in the client’s
best interests, and encouraging client autonomy, e.g.,
by obtaining meaningful informed consent. These
legal and ethical obligations are acquired by practitioners because each obligation is generated by a concomitant client right, e.g., the client has a right to con-
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fidentiality and thus a practitioner has an obligation
to protect and promote that right.
In practice, many consider the practitioner to be in
a one up position because of her or his expertise, the
implied status of her or his position and education, the
client’s hesitation or inability to confront such an
authority figure, and the practitioner’s freedom to
reject entering the relationship, whereas the client
may be too desperate for service to reject entering the
relationship even if he or she does not like the particular practitioner.
Biofeedback ⎪ Spring 2005
Friendships Versus Practitioner-Client
Relationships
Some have argued that a treatment relationship is
nothing more than a paid friendship (Bayles, 1988).
Yet, nothing could be further from the truth if the
relationship is an ethical one. Friendships have very
different rules than do professional relationships. For
example, in a friendship both parties often disclose
personal information, but in a professional relationship the focus is on helping the client; thus, personal
information is seldom revealed by the practitioner. If
personal information is revealed, it occurs because it is
deemed to be a way of helping the client to achieve his
or her treatment goals. Practitioners do reveal information about their practice approach, education and
background to practice, licensure status, rationale for
treatment, and so on.
Friends are expected to take each others’ needs more
seriously than those of other people. Practitioners are
expected to focus their attention on the needs of the
client and to get their own needs (other than being
reimbursed for the services that they provide) met in
other ways, by other people. If fact, it is unethical for a
practitioner to strive to have his or her personal, social,
physical, or other needs met by his or her clients. Fried
(1981) pointed out that: a) the professional-client relationship is unidirectional (focus only on needs of the
client), b) friendships are between equals and practitioners are in a one-up position, and c) friendships are
entered into because of an affective/emotional component, but the professional-client relationship is entered
into by the practitioner as an exchange of a fee for a
service. In fact, clients seek out the services of a practitioner precisely because they believe that the practitioner has knowledge and skills that he or she as a
client does not possess, but that he or she believes
would be helpful if properly applied.
Paternalism Versus Autonomy
A client’s belief in a practitioner’s expertise not justify a practitioner behaving in a paternalistic manner
(i.e., assuming he or she knows better than the client
what is good for him or her as a client) toward the
client. Practitioners realize, or should realize, that
they are ethically (and in many states, legally) expected to involve the client in the decision-making process
via meaningful informed consent.
“A central issue in the professional-client relationship is the allocation of responsibility and authority in
decision making—who makes what decisions” (Bayles,
1988, p. 113). The current ethical and professional
environment emphases autonomy rather than paternalism; i.e., clients are to be informed of their choices
so that they can make informed decisions and consent
to participate in the interventions with which they
agree. In their study of informed consent, Lidz et al.
(1984) reported that most practitioners were not
obtaining a written informed consent, and that included physicians who were required by law to obtain it.
This is hopefully changing as more laws and ethical
principles and practice standards require informed
consent. For example, AAPB’s guidelines and standards now require practitioners to obtain informed
consent (Striefel, 2004). Clients hire practitioners to
act in their best interests. Obtaining informed consent
is part of that contract. Do you obtain valid informed
consent from each client? If not, why not?
It is important for practitioners to realize that they
are being paternalistic when they intend to do something to or for the client regardless of the client’s consent. Even if the client actually consents to an intervention, it is paternalistic if the practitioner intended
to go ahead even if the client did not consent. The
intent by a practitioner to manipulate a client is paternalistic and is dishonest as well. Practitioners who
have such intentions should realize that they are
beginning to cross the line from being ethical to
unethical. Practitioners need to be careful not to provide false information, withhold needed information,
slant information, or place more emphasis on some
facts versus others as a way of manipulating a client
to consent to a treatment that he or she might not
otherwise consent to receive. For example, a biofeedback practitioner who is not competent to do cognitive-behavior therapy should not emphasis neurotherapy as the treatment of choice for treating
depression when current research makes clear that
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Ethical Practitioner-Client Relationship
Spring 2005 ⎪ Biofeedback
cognitive-behavior therapy, medication, or combinations of the two seem to be the treatment of choice.
This is not to say that when a client is informed about
the status of cognitive-behavior therapy and medications for treating depression as part of the informed
consent process that he or she cannot also be
informed about the status of neurotherapy and why
the particular practitioner supports its use for a particular client. This assumes, of course, that the information provided is accurate, honest, and complete, so
that a client can make an informed decision. In my
experience, clients seldom reject a treatment just
because it is not the treatment of choice supported by
the research or clinical literature, if there is a reasonable rational for proposing a different treatment for
that particular client; e.g., the treatment of choice has
been tried and did not work for this particular client
or is not an acceptable option for this client.
I recently had some dental surgery and the periodontist got ready to give me a shot of pain killer
without saying anything to me about it. I told him
that I did not want it. He got upset, so I explained that
I had been using self-hypnosis successfully for years
for dealing with pain during dental procedures. He
finally agreed to go ahead, and since I showed no signs
of pain during the procedure, he finally admitted that
it was as much for his own comfort as that of the
patient that he routinely, without informing the
patient, used a pain killer. His needs versus those of
the client seemed to take a priority. It is useful to
remember that we all develop habits as practitioners
and not all of them are for the benefit of all clients.
Due care to what a practitioner does or does not do
with each individual patient on an individualized basis
is important.
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Boundaries and Dual Relationships
Some dual relationships become, or are potentially
problematic, precisely because the professional-client
relationship is different from a friendship.
Practitioners are expected to establish and maintain
certain boundaries when entering into a professionalclient relationship as a means of avoiding harm to the
client, as a means of best meeting the client’s needs,
and as a means of preventing foreseeable problems for
the practitioner. The practitioner, not the client, is
responsible for knowing what the boundaries are and
for maintaining them. Some important boundaries
include: a) no sexual activity with clients, former
clients, or those closely associated with clients; b) no
problematic dual relationships with clients; e.g., being
a client’s business partner or best friend, c) no involvement or due care in entering into conflict of interest
situations that might lead to exploitation of clients
(e.g., bartering), d) keeping the best interests of the
client as a priority, and e) when a client is present in
the office, doing only treatment and related activities
(e.g., avoid socialization during sessions that could
erode boundaries). See Striefel (2000) for more information on boundary issues and how to resolve them.
Before entering into a dual relationship, a practitioner needs to consider what the issues are. Issues to
be considered include: when and where treatment will
occur, what services will and will not be provided, why
might the practitioner enter into a dual relationship
(e.g., it is the only way the client can get a needed
service), what will these services cost, and how problems caused by the dual relationship will be resolved.
Consideration must also be given to the possibility
that the nontherapeutic relationship may be terminated or put on hold, how informed consent will be
handled, and if and what level of supervision or consultation might be needed. Careful documentation
must be considered and must occur. Why consider all
these factors?
Responsibility and Authority
Practitioners have obligations to clients and to third
parties (the family of clients, society, referral sources,
third-party payers, etc.) that may conflict with the
best interests of the client. Ethically, practitioners are
expected to keep all parties informed of their loyalties
and to try to resolve such dilemmas in an ethical and
legal manner (APA, 2002), being careful to document
their actions and rationales in the client’s file.
Practitioners are expected to exercise their expertise,
skills, and make objective decisions—involving the
client to the degree appropriate to the specific situation, but doing so with due attention to the ethical
principles, client rights, and relevant laws.
In deciding whether to form a professional relationship with a particular client, practitioners consider their own areas of competence, the potential needs
of the client, any existing conditions, biases, or other
factors that might interfere with forming a good relationship or with generating positive outcomes to
treatment. Practitioners should not accept into treatment clients whose needs exceed or fall outside of
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their areas of competence, unless appropriate supervision or consultation is available that will allow them
to meet or exceed the minimal expected standards of
care. In some cases, it is better to refer a client elsewhere for treatment and practitioners should know
when such a situation exists.
Referrals
Sometimes a client presents with one problem which a
practitioner is competent to treat and then it turns out
Biofeedback ⎪ Spring 2005
Practitioner-Client Disagreement
Concerning Treatment
Sometimes a client wants a treatment that a practitioner does not believe is in the client’s best interest.
The client requests that particular treatment and will
not consent to having that treatment withheld. The
practitioner is then faced with a dilemma. Should he
or she provide the treatment the client wants even
though he or she does not believe it is in the client’s
best interest? If so, how does the practitioner explain
his or her reasons for not wanting to provide the
requested treatment, including the likelihood that the
third-party may well not agree to pay for the service?
What is his or her rational for proceeding with the
treatment? How does he or she document this in the
client’s file? What if the desired treatment could produce more than minimal discomfort or harm for the
client? After all, a practitioner has an ethical obligation to prevent or minimize harm to a client and to
have informed the client and obtained client consent
before using such an intervention. Practitioners can
be sued if a client is harmed or believes he or she was
harmed by what the practitioner did or failed to do.
Clearly, this is a complex issue that must be thought
through carefully.
The practitioner of course, does have the right to
refuse to provide the requested intervention, if he or
she does not believe it is in the client’s best interests.
Is doing so without careful consideration being paternalistic? If serious harm could occur to a client by
agreeing to provide the requested treatment then the
practitioner is on reasonably good ethically grounds
for refusing to provide the treatment. But what
biofeedback or applied psychophysiology interventions are known to cause serious harm? Can you
think of one? Physicians of course face all sorts of life
and death situations.
A client can be referred elsewhere when a practitioner and client cannot agree on the provision of a
treatment. In some cases, a practitioner may well
agree to provide a treatment that he or she does not
believe is in the client’s best interests, because: a) the
client has been informed of the potential risks and
benefits of the requested treatment (e.g., which is not
supported for use with the client’s presenting problem
and therefore may well not work, the treatment sessions cost dollars and the insurance company is
unlikely to pay for the sessions, etc.), b) the practitioner has explored why the client wants the particular treatment and has tried to clear up any misconceptions, c) no serious harm is foreseeable, d) the client
has been informed of more viable treatment options
(treatments of choice) and their risks and benefits, but
still refuses to receive one or more of them, e) the
client signs an informed consent form voluntarily
indicating that he or she understands all of the factors
discussed above, but still wants the specific treatment,
and f) the practitioner knows that client expectations
and beliefs concerning a particular treatment may
well make it effective, at least in the short term —
what Wickramasekera (2003b) calls the placebo effect.
In making the decision about the treatment the
client wants, the practitioner needs to determine
whether the client has the capacity to understand the
information provided, actually understands it, voluntarily consents to receive it, and is free of any emotional or psychological disturbance that would interfere with him or her making a rationale decision, i.e.,
making sure the client meets the conditions needed
for obtaining a valid informed consent. Sometimes
the desire for a particular treatment choice is based on
a difference in values between the client and the practitioner. A client’s values need to be respected even if
a practitioner does not agree with them. Good rapport
and trust are critical components in whether or not a
client will defer to a practitioner’s judgment when he
or she personally desires some other intervention
with which the practitioner does not agree. It is
important to allow and encourage client autonomy.
After all, biofeedback is all about a client taking control of his or her physiology and other aspects of his
or her life, including behavior, beliefs, attitudes, etc.
Paternalism seems to be appropriate only when a
client is not competent to make the required decisions. Even then, ethical practitioners involve a parent, guardian, advocate, or consultant in the decisionmaking process.
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Ethical Practitioner-Client Relationship
Spring 2005 ⎪ Biofeedback
that the client has other needs that the practitioner is
not competent to treat. Sometimes one treatment
seems to be the treatment of choice for a client, but it
does not work, and so another treatment is needed, one
that the practitioner is not competent to provide. In
those situations an ethical practitioner will help the
client access services from another practitioner who has
the appropriate expertise. He or she might even
arrange to be an observer to the treatment in an effort
to learn how to provide such treatment competently.
Ethical practitioners do not abandon a client in need,
especially when the client’s problem is serious or where
detrimental consequences could occur to the client.
In addition, practitioners need to be cognizant
when they make referrals to not make a referral to a
practitioner who has a reputation for being incompetent. Such a referral could be considered negligence
(Stromberg et al., 1988). The best way to make referrals is to give the client the names of several other
practitioners and to let the client choose whom to see,
and to make clear to the client, that he or she as a
practitioner does not know if the other practitioner
can help the client. The practitioner can emphasize the
importance of the client asking the other practitioner
whether he or she believes he or she can help the
client with his or her problem(s). The referring practitioner should help the client throughout the referral
process as needed. Common practice is for practitioners to make referrals to a specific source that they
know. This may or may not be the best way to proceed
from an ethical and legal perspective.
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Hypnosis: Implications for the
Practitioner-Client Relationship
Wickramasekera (2003a) discussed strategies for gaining the cooperation of patients with a somatization
disorder. The practitioner-client relationship is very
important in treating patients with such disorders. A
somatization patient is defined as one who hides from
threatening psychological information and who
expresses his or her emotional distress via physiological symptoms (Wickramasekera, 2003a). Such patients
are often told by their doctor that it’s all in your head
(Wickramasekera, 2003a). Getting cooperation often
involves treatment of the somatic symptoms using
mind-body approaches such as hypnosis, biofeedback,
cognitive-behavior therapy, or other treatments.
Hypnosis, biofeedback, and cognitive-behavior therapy are good interventions for helping a client to learn
how to change his or her physiology via self talk,
thoughts, images, shifts in beliefs, etc.; i.e., for learning
about the mind-body connection. Treatment also
involves forming a meaningful relationship with the
client (Wickramasekera, 2003a). A positive transference relationship may occur during the treatment of
the somatic symptoms so that the client sees the practitioner as having credibility because the symptoms
were treated first. This may allow the client to talk
about threatening secrets that have not been allowed
into consciousness before, but which may have been
the cause of the somatic symptoms.
Hypnosis may be used to access such information;
however, this does not absolve the practitioner from
his or her ethical obligation to obtain valid, truthful,
and meaningful informed consent. Wickramasekera
(2003b) defined hypnosis as a method of information
processing in which awareness and analytical thinking
is suspended, leading to involuntary changes in perception, mood, and memory that can produce profound changes in behavior and biology. Collins et al.
(2003) say that hypnosis is something a client allows
to happen to him or her and not something that someone else did to them. How do you obtain valid
informed consent when using hypnosis? Practitioners
need to avoid deception unless that has been included
as part of the informed consent process. Milton
Erickson is reported to have induced hypnosis with
patients and other people without either their awareness or consent. This is not ethically acceptable for
practitioners today. Wickramasekera (2003b) said that
hypnosis induces a more rapid onset of states produced
during psychotherapy, such as, regression, abreactions,
and the uncovering or psychodynamic information.
Clients need to be informed if abreactions or disturbing information is likely to come to conscious awareness when using hypnosis since they are foreseeable
risks, much like would be done if using autogenic
training. Obtaining valid informed consent should not
be a difficult process if careful planning occurs.
Experiencing hypnosis for oneself can be useful in
planning the informed consent process for clients. It
can be useful to plan how to obtain informed consent
for different kinds of presenting problems (headaches,
back pain, asthma, etc.) and for different types of
interventions (e.g., hypnosis, biofeedback, or cognitive-behavior therapy). Discussion and review of the
process to be used with another knowledgeable and
competent practitioner can be most helpful.
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References
American Psychological Association. (2002). Ethical
principles of psychologists and code of conduct.
Washington, DC: Author.
Bayles, M. D. (1988). The professional-client relationship. In J. C. Callahan (Ed.), Ethical issues in professional life (pp. 113–120). New York, NY: Oxford
University Press.
Fried, C. (1981). Contract as promise. Cambridge, MA:
Harvard University Press.
Lidz, C. W., Meisel, A., Zerubavel, E., Carter, M., Sestak,
R. M., & Roth, L. H. (1984). Informed consent: A
study of decision making in psychiatry. New York,
NY: Guilford Press.
Stromberg, C. D., Haggarty, D. J., Mishkin, B.,
Leibenluft, R. F., Rubin, B. L., McMillian, M. H., and
Trilling, H. R. (1988). The psychologist’s legal handbook. Washington, DC: National Register of Health
Service Providers in Psychology.
Striefel, S. (2000). Professional boundary issues in neurofeedback and other biofeedback. Biofeedback, 28, 5–6,
& 12.
Striefel, S. (2004). Practice guidelines and standards for
providers of biofeedback and applied psychophysiological services. Wheat Ridge, CO: Association for
Applied Psychophysiology and Biofeedback.
Wickramasekera, I. E., II. (2003a). The placebo effect
and its use in biofeedback therapy. In D. Moss, A.
McGrady, T. C. Davies, & I Wickramasekera, II
(Eds.), The handbook of mind-body medicine in
primary care (pp. 69–92). Thousand Oaks, CA:
Sage Publications, Inc.
Wickramasekera, I. E., II. (2003b). Hypnotherapy. In D.
Moss, A. McGrady, T. C. Davies, & I Wickramasekera,
II (Eds.), The handbook of mind-body medicine in
primary care (pp. 151–166). Thousand Oaks, CA:
Sage Publications, Inc.
Sebastian “Seb” Striefel
Correspondence: Sebastian Striefel, PhD, 1564 E 1260 N,
84341-2847, email: Sebst@msn.com.
Logan, UT
Biofeedback ⎪ Spring 2005
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