In this post, “wishes” refer to what a client says that they want for themselves, whereas “interests” refer to what is objectively beneficial for their well-being. When mental health professionals (MHPs) are working with clients, the duty to respect the client’s right to self-determination ordinarily means that the MHP should focus on the client’s wishes (American Counseling Association, 2014; American Psychological Association, 2017; National Association of Social Workers, 2021).
When clients voluntarily seek services, they generally have a right to establish their own goals for work and determine what forms of therapy or help they want to pursue these goals. If, during the assessment process, the MHP determines that the client’s interests conflict with their wishes, the MHP may discuss these concerns with the client. Still, the clients generally retain the right to pursue goals and forms of support that may not align with their interests. Prioritizing the client’s wishes demonstrates respect for the dignity and worth of the client, including their right to autonomy and choices over how they live their lives. It also affirms the MHP’s belief that the client is an expert in their own life. The right to self-determination includes the right of a client to make mistakes or, perhaps, mistakes as perceived by the MHP.
To illustrate the difference between wishes and interests, consider an MHP who is working with a client with an eating disorder. Upon discussion of therapeutic alternatives for helping the client with the eating disorder, the client refuses any form of help. This refusal reflects her expressed wish; however, accepting help may be in her best interests. Rather than coercing the client into therapy for her own best interests, the MHP’s obligation is to respect the client’s wishes. The MHP could leave open the possibility for therapy in the future, letting the client know that it is OK to return to the MHP for assistance.
Exceptions for Clients Without Mental Capacity or Legal Competence
Clients may lack mental capacity to make legal decisions due to their developmental stage, cognitive impairment, dementia, or brain injuries. Legal restrictions on the right to self-determination and informed consent may also apply to minors (those under 18) or individuals declared legally incompetent by a court. In these circumstances, a proxy—typically a family member or someone appointed under a durable power of attorney—has the duty to provide consent on the client’s behalf (Wade & Kitzinger, 2019). When MHPs are working with clients who lack mental capacity or legal competence, they have a stronger duty to consider and advocate for the client’s interests. They may ask these clients for assent, but there are situations where they could justify providing services without explicit permission from the client.
Consider an older adult with dementia who wishes to continue living independently in their private home, while their adult children believe that moving into an assisted-living facility is necessary. During intake at the facility, an MHP determines that the older adult lacks mental capacity, meaning that “legally” the adult children may move forward with their plan. Ideally, the MHP should try to accommodate both the client’s wishes and interests, perhaps by helping the family consider various options. If the adult children are not adequately considering both the client’s wishes and interests, the MHP can employ advocacy or other conflict management strategies to help them do so.
Exceptions for Forensic Evaluations
Forensic evaluations present a special scenario in which MHPs must be clear about their legal and ethical responsibilities. During forensic evaluations, MHPs are not providing treatment or therapeutic services but, rather, assessments to be used to inform court decisions (Barsky, 2024). In a divorce situation, for instance, a parenting plan evaluator may be hired to evaluate what type of parenting arrangements serve the child’s best interests. When determining what is in a child’s best interests, the evaluator should consider the child’s wishes. Typically, however, state laws regarding a child’s best interests include the child’s wishes as just one factor to consider.
Exceptions for Serious, Imminent Harm
A critical exception for the duty to prioritize a client’s wishes arises when those wishes pose a risk of serious, imminent harm. If a client in acute distress requests assistance with suicide, the MHP’s obligation is to prioritize the client’s safety and well-being, even if this means overriding their immediate wishes (Barsky, 2023). The harm is serious and imminent. On the other hand, if a client refuses help with a cigarette addiction, an MHP can educate them on risks, but should ultimately respect the client’s choice to continue smoking. Although smoking poses serious risks, the risks are not imminent.
Conclusion
It may feel tempting for MHPs to want to provide help to clients in a manner that prioritizes their interests and well-being, even in situations when such help goes against the client’s stated wishes. It’s vital for MHPs to understand the difference between wishes and interests, as well as the legal and ethical frameworks that determine which factor should be prioritized. It is also prudent for MHPs to use good therapeutic and conflict management skills to help clients and family members make decisions that accommodate both the client’s wishes and interests (Barsky, 2017).
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the 988 Suicide & Crisis Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.
