What are two problems associated with the paternalism that prevailed in healthcare until the 1950s?
- People were unable to be involved in their own care
- Abuse was rampant
Informed consent and refusal was created mostly due to what?
By the 1970s mental health philosophy shifted from paternalism to what?
By the 1970s case law established that patients had what three basic rights?
- informed consent
- informed refusal
- voluntary release of information
What is informed consent?
- The therapeutic contract
- the document at the beginning of therapy that gives the counselor permission to conduct therapy
What is informed refusal?
The right to refuse treatement, including medication as long as the client is not a danger to themselves or others and can take care of themselves.
What is the voluntary release of information?
Patients have the right to decide what information gets shared and when.
What are three components of informed consent?
What does capacity mean?
- the individual is able to make rational decision
- the ability to understand
What does comprehension mean?
- the individual is given adequate information and understands the information sufficiently
- Are they actually understanding
What is voluntariness?
The individual has given their consent freely and without coersion
What three circumstances might occur that don't require the same informed consent from clients?
- Clients in crisis
- Court mandated clients
What two things are important to remember about informed consent when dealing with a client in crisis?
- Try to get apparent consent, which means we want them to aggree that they need help
- Try to balance nonmaleficence with autonomy. They are still individuals with rights, but we need to ensure that no harm is being done.
Why don't court mandated clients have to sign informed consent?
They are choosing between jail and therapy, so they don't have as many rights
What three things should you try to remember when working with court mandated clients?
- provide an appropriate explanation
- seek the individual's assent
- consider preferences and best interests of the client
What two things should you remember when working with minors?
- Always seek assent
- under 14 requires parental consent
What are four common myths about informed consent?
- It is complete after signing
- Clients always understand what they read
- Clients always remember what they read
- It is a nuisance and a distraction from therapy
What are four truths about informed consent?
- It is an ongoing process which is presented gradually and repeated over time
- Should be written at a sixth grade level
- It should be readable and about the client
- It makes the therapist/client relationship stronger
Informed consent is
beneficial to clients
What is not part of informed consent?
The minimum requirements for OR LPC and ACA ethical codes for what should be included in informed consent are
- client's access to their records
- client's right to choose their counselor and be active in treatment planning
- client's right to refuse counseling & the implications of doing so
- client's right to ask questions and get answers that make sense
- It must be written
what question might we ask when creating an informed consent?
If I were a client, what topics would I want to be included in the informed consent.
Who needs to have a personal disclosure statement?
- every applicant for licensure
- every LPC, LMFT, and intern practicing in Oregon
What is included in a professional disclosure statement?
- name and contact information
- philosophy and approach
- education and training
- name of supervisor if intern
- name and address of board
What is documentation?
- Goals and rationale
- demonstrates that you provided the services that you are getting paid for
- will save your ass if you get sued
in Oregon what is considered part of client records?
- interview notes
how long should you keep records for?
no less than 5 years
what does HIPAA stand for?
Health Insurance Portability and Accountability Act
what is the purpose of HIPAA?
to protect consumers' rights to health insurance and confidentiality of records
what three things should you avoid when creating records?
- detailed discussions of other people
- sensitive or embarrassing information
What are the four main parts of clinical documentation?
- Treatment Plans
- Progress Notes
- Discharge Plans
What are assessments?
- Done at the beginning
- comprehensive history of client and situation
- How are they doing in the day to day living
What are clinical formulations?
- 2-3 paragraphs that illustrate your expertise.
- figure out what the problem is and which interventions to use
- expected outcome and justification for treatment
what are treatment plans?
- the roadmap for therapy
- what is the main goal, and then what smaller pieces can we tackle on our journey to the main goal.
- measure if symptoms are changing
When should you write progress notes?
after every session
What is a discharge plan?
- summary of what happened in therapy
- recommendations about how and when to reenter treatment
- relapse prevention plan
What is privacy?
The right to decide what information about themselves will be shared, and what will be kept private
What is confidentiality?
everything that is said when we go to therapy (with a few exceptions) is confidential
What should you do to ensure that the client understands when you will breach confidentiality?
put it in the informed consent
What is privilege?
the legal term for confidentiality
Does privilege go away when a client dies?
no, you must get next of kin or lawyer to give consent
what are four main reasons that confidentiality is so important?
What are the seven limits to confidentiality?
- Client requests release
- court orders
- client makes a complaint
- danger to self or others
- groups and couples
Oregon law and HIPAA say that records should be release to what three entities at the patient's request?
- Other health providers
- the patient
What are three responsibilites that a counselor has when releasing information?
- release no more than necessary
- assist client in determining what to release in order to meet goals
- attempt to ensure that the recipient keeps the information confidential
Releases of information must be:
- In writing
- Contain language about non-redisclosure
- In compliance with HIPAA
- Fully explained to clients
Under what three circumstances do clients waive their right to privilege?
- If they bring legal action against a counselor
- File an ethics complain against a counselor
- Rely on their mental or emotional condition as an element of their claim or defense.
We are mandatory reporters for abuse against what types of people?
- Mentally ill/divelopmentally disabled
What three items came out of the Tarasoff Ruling with respect to Duty to warn?
- must warn when therapist believes client is a clear and imminent danger
- client has indicated a specific victim
- therapists must warn the victim and the authorities
When must LPC's in Oregon report with respect to duty to warn?
when a communication reveals the intent to commit a crime or harmful act.
Wen may a counselor initiate involuntary commitment?
- When client is a danger to self or others
- When client is unable to provide for basic personal needs and is not receiving such care as is necessary for health or safety.
In oregon when can a minor seek treatment without parental knowledge?
How can therapists address confidentiality with couples and groups?
- have all parties sign an informed consent
- educate them about professional ethics and moral responsibility.
What are Pederson's three ethnographic variables?
- Ethnicity -- may overlap with race, but more about values, world views, and customs.
What are Pederson's three deographic variables?
- Gender -- masculinity and femininity. What does it mean to be a man or a woman
- Location of residence -- culture is impacted by region. What values does their community have
What are Pederson's three status variables?
- Social -- how do people interact with each other
- Economic -- how do they deal with money
- Educational -- both formal and life education
What are Pederson's two affiliation variables?
What do affiliation variables deal with?
how we address people and how we communicate with each other. either formal or informal
What does Triandis' notion of shared world view provide understanding of?
- how well the person fits with values and beliefs of their primary group
- How much majority view has been assimilated by client. This measures acculturation
what perspective focuses on a universal perspective that looks at sameness as more important than differences and believes counseling practices apply across cultures?
What perspective is culture-specific and stresses the importance of recognizing differences?
What bias do we risk when we focus mostly on how similar we are?
that the dominant culture is right and if we are different we are wrong.
What is the danger of focusing on differences?
We may rely on stereotypes
Pedersen suggested a more enmeshed perspective of etic and emic by saying they were each part of the process in what ways?
working alliance is etic factor, means of establishing it is emic.
Culture is defined as
- Shared elements of language, history, and geographic location.
- It is the most general and inclusive
Race is defined as
- Classifications based on physical characteristics
- biology and anthropology in perspective
What is ethnicity?
Common ancestry with shared values and customs
who are minorities?
Groups whose access to power is limited by the dominant culture
What are the five compenents that privilege uses to maintain itself?
What is bias?
Bias is a tendency or habit of thinking, feeling, or acting in a particular way.
When can bias become stereotypes?
when it is rigid
What is stereotyping?
generalized beliefs about members of a social group.
What is prejudice?
- preformed and unsubstantiated judgment or opinion about and individual or group either favorable or unfavorable.
- Generalized attitude toward members of a social group
What does prejudice rely on?
how much more do hispanics and african americans pay on average for the same house?
What is discrimination?
Behavior directed toward people based on group membership
What does privilege maintain?
how are prejudice, stereotypes, and discrimination described?
- Prejudice is the attitude
- Stereotypes are the beliefs
- Discrimination is the behavior
What is the counterpart to discrimination?
unearned privilege or opportunities and positive expectations that come from not being a minority.
What are examples of unearned privilege
- white skin
- male/female privilege
- heterosexual privilege
- able-bodied privilege
- middle class privilege
What is "privilege"
higher status that allows one group benefits more than other groups
Where does privilege typically occur?
in areas that we have knowledge about or the most experience in.
What contributes to our identity and expectations about our lives?
How can we deal with our privilege?
assist under-privileged individuals in being empowered to gain more privilege and deal with institutional oppression
When can we believe that our lives and how we do our work is free from bias and judgment?
What is one of the largest biases that we may hold?
- inflexible focus on individualistic world view.
what does ADDRESSING stand for?
- socioeconomic status
- sexual orientation
- indigenous heritage
- national origin
Sometimes clients want a more flexible relationship, but as the professional it is our job to:
Set and maintain boundaries
What is a multiple relationship?
A relationship that is happening in two ways with the same person
When does a multiple relationship occur?
- when the therapist is also in another role with client
- when the therapists is in a relation ship with a person closely related to the client
- when there is a promise of a future relationship with the client or a person close to the client
Is it unethical to have a profession to professional relationship?
it isn't explicitly unethical, but should be carefully evaluated
Is it unethical to have a professional to personal relationship?
likely to be unethical and should be carefully evaluated
is sexual attraction unethical?
attraction is okay and happens. It isn't unethical, but it should be carefully monitored
attraction is fine, but sex is
When should counselors avoid entering into a dual relationship?
when it could impair professional judgment or increase the risk of harm to clients
when engaging in a dual relationship what do counselor need to use?
- informed consent
when is a multiple relationship ethical?
- not exploitative
- doesn's cause impairment
- potentially beneficial to client
what does the ACA and APA say about Sexual multiple relationships?
- Therapists don't engage in sex with current clients
- Therapists do not provide therapy for former sexual partners
- Therapists who do engage in sex with former clients must wait a certain amount of time
What are the time periods for waiting to have sex with former clients for the APA, ACA, and OR LPC?
- APA 2 years
- ACA 5 years
- OR LPC 3 years
How common is sexual attraction in therapy?
87% of therapists endorsed sexual attraction to a client
what percentage of therapists reported becoming sexually involved with a client?
What are some potential predictors of acting on sexual attraction?
- excitement or longing for session
- romantic daydreams about client
- you touch or desire to touch client more than others
- you have engaged in post-therapy relationships with clients in the past
What should you do if you are attracted to a client
- acknowledge feelings
- understand why you are attracted
- seek consultation
- set clear boundaries
- do not touch patient
- refer if unable to resolve
What percentage of clients are adversely affected by sex with their therapist?
how can sex with clients hurt them?
- mistrust other therapists
- impaired emotional social or sexual adjustment
- increased suicidality
- less likely to seek subsequent therapy
what percentage of complaints opened by the APA were sexual misconduct complaints?
What conditions must be true for ethical post therpy sexual relationships
- termination of therapy could not have happened in order to facilitate relationship
- therapy was brief and not deeply personal
- must have been initiated by client
What do you do if a client is sexually attracted to you?
- Be clear
- Set limits
- Say no
- Be direct
What is a boundary crossing?
departure from commonly accepted practices that could potentially benefit clients
What is a boundary violation?
a serious breach that results in harm to clients
What are the risks associated with non-erotic touching?
- client may misunderstand
- higher risk of developing sexual relationships
- blurred boundaries
what are the benefits of non-erotic touching?
client may feel suppoted in a time of need
What are the risks associated with accepting gifts from clients?
- therapists may give special treatment
- may be a sign that the client feels unworthy of attention
- blurred boundaries
What are the benefits of accepting gifts from clients?
may give clients a way to express appreciation
what guidelines should you follow with regards to gift giving?
- should be at end of treatment not beginning
- don't let it compromise objectivity
- should be rare and not recurrent
- not expensive
What are the risks associated with bartering?
- blurred boundaries
What are the benefits of bartering
may give client who don't have the means a way of paying for treatment
What are the guidelines for bartering?
- have a contract
- use goods with an easily definable value
- collaborate with client to determine value
what percentage of mental health costs occur in inpatient and residential settings?
what percentage of patients use inpatient or residential settings?
Where were the bulk of mental health costs incurred between 1960 and 1990?
inpatient services at non-profit organizations
What are the four reasons that mental health is getting more expensive?
- psychotropic medicine and assessments are more expensive
- More people are seeking services
- Clinical abuse
- Inpatient very costly
What are five reasons that health care costs are increasing?
- Aging population
- Higer expectations from patients
- Increase in malpractice suits
- Higher cost of administration
- Improved technology
What percentage of the GNP is health care estamated to be in 2011?
What are four reasons for managed care?
- Practioners were the ones making decisions (oversight)
- Sky rocketing health care costs
- Corporations taking the brunk of the costs
- Need for stricter resource management
What are the four types of managed care?
What are the characteristics of an HMO?
provide insurance to clients and deliver services through their own providers
What are the characteristics of a PPO?
Clients can go to providers either in or out of network, but get financial incentives for choosing in network providers
What are the characteristics of a POS?
- hybrid of HMO and PPO
- PCP contracted by POS
- Options to see other out of network providers
What are some cost controlling strategies?
- Session Limits
- Cover less expensive alternatives
- pre-treatment authorization
- Practice profiling
What are some concerns for minorities under MCOs?
- Provider awareness
How can counselors manage client abandonment in MCOs?
- Referral to public agencies
- Referral to self help groups
- Schedule sessions less frequently
What is a parity law?
- Mandates that insurance companies provide the same coverage for mental health and addiction treatment as they do for general health.
- Deductibles and coinsurance can't be greater than those for other medical treatments
- End limits to number of visits
How can counselor's manage session limits?
- Train in brief treatments
- Know appeal process for each MCO you join
What are some ethical considerations of belonging to a managed care organization?
- MCO wnats cost effectiveness, but ethical guidelines require patient allegiance
- Patients who need more care may not have services covered
What makes up knowledge of cost effecive treatments?
- Use of effectiveness literature
- Training in effective treatments
- Brief treatments
- Group treatments
- Preventative services
- Step care treatment
What are some problems with gatekeeping?
- Prefer pharmacological interventions
- Poor assessments
- Often dont use DSM criteria
What are the consequences of managed care on mental health?
- Limited number of providers on panels
- Obsession with cost
- Changes in services available and who can deliver them
- De-empasizes psychiatric hospitalization
- More paperwork
- More ethical dilemmas
In what ways can crossing a boundary be beneficial to a client?
- Strengthen therapist and client's working relationship
- Can help client re-think a certainty
- Emotional growth
- Reach treatment goals
What is the secon most reported ethical dilemma?
Blurred, dual, or conflictual relationships
What are five potential causes for boundary crossing being such a challenge for professionals?
- They catch us off guard
- They often tap into basic needs or strong desires
- Need for clarity seen as inflexibility
- They often evoke fear or anxiety
- Very little real world guidance
What factors should be considered when determining if a boundary crossing is likely to help or hurt?
- Theoretical orientation
When are dual role relationships likely to lead to harm?
- Expectations between roles are incompatible
- Loss of objectivity
- Increased power or prestige increases potential exploitation
In what ways can boundary crossing be risky?
- It can knock therapy off track
- Sabotage the treatment plan
- Offend, exploit, or harm the patient