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Principle ethics
Set of obligations between principle and virtue ethics
Ex: "What am I going to do best for my client?"
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Virtue ethics
focuses on character traits of counselor and no obligatory ideals to which professionals aspire rather than on solving
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Each professional organization has its own _______ you must abide to
Code of Ethics
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Code of Ethics: 3 Objectives
- 1. Educate professionals about good conduct
- 2. Ethical standards provide a mechanism for professional acountability
- 3. Code is catalyst from proving practice generally
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Aspirational ethics
Highest standard of thinking
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Positive ethics
Making sure we can do better things with clients
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Pro bono
Free services to a client
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Nonmaleficence
Avoiding doing harm
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Beneficience
Promote well being of clients
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Justice
Treat others equally
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Fidelity
Make realistic comments, keep promises
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Veracity
Be honest with client
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Goal: Enchance relationships
But PROBLEMS....
- Dicuss finances (OUTSIDE OF SCOPE)
- Do not make reports to police
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3 Things Needed for Scope of Competence
- 1. Education
- 2. Training
- 3. Experience
ALSO ASK FOR PERMISSION FROM CLIENT
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Scope of Practice/Scope of Competence:
Jack with LMFT Ph.D. And thousands of hours or experience and is contracted to administer a psychological test
- Inside Scope of Competence
- He has his PhD, if he just had LMFT then no because MFT cannot administer tests
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Scope of Practice/Scope of Competence:
Jill is asked to do EMDR, she is not trained and she does 20 minutes of research
- Outside Scope of Competence
- She does not have sufficient training
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Scope of Practice/Scope of Competence:
Dick LMFT 3 years of practice working with couples and begin treating someone with multiple personalities
- Outside Scope of Competence
- Unless he consults and gets more training
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Scope of Practice/Scope of Competence:
Jane LMFT specializes in domestic violence is treating battered woman in free clinic
Client can't afford to see doctor, tells client she can get medications to help her sleep
- Outside Scope of Practice
- She can't give medical advice or prescribe medication
- Might be competent
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Do we contact police if a client has committed a crime?
- NO!
- Unless it is harm for others
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What does a Marriage and Family Therapist do?
- Assess, Diagnose, and Treat
- Couples, Individuals, Families, and Children
- Work with relationship issues/Enhance relationships
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Things to say when we have something we can react to from countertransference
- "I didn't see that coming..."
- "Oh that breaks my heart..."
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If we have an angry client...
Attack the anger
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Countertransference
- Projection by therapists that distort the way they perceive and react to a client.
- Learn to discern values and countertransference
- Can be overprotective because of countertransference
- Obligated to feel the need to take care of needy ones
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Transference
Clients project onto their therapists past feelings or attitudes they had toward their caregivers or significant people in their lives
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Standard of Care
- Doing what is reasonable and prudent in our prefession
- What is used if you are accused of malpractice or negligence
- Do a thorough informed consent, diagnosis, assessment (history), and treatment plan
- Keep clients safe and unharmed
- CONSULT with colleagues and other professionals
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Maintaining Confidentiality
- Can consult and share with colleagues
- If clients pass away, still keep files safe and confidential (unless executor has documentation allowing release of info)
- Keep files for 7 years after they turn 18
- Group therapy ⇒ Can't speak outside the group
- Keep medical conditions in separate folder
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MAY break confidentiality
- When client is suicidal
- Client consent (after signing authorization)
- 3rd party payer (insurance, victims of crime)
- Other mental health people (do NOT use names or details)
- Subpoena
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If you have a client with HIV...
- Keep separate folder with "General Medical Condition"
- Must talk about it in the beginning
- Keep current with current medical condition changes
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MANDATED to break confidentiality
- DUTY TO WARN AND PROTECT
- Danger to others
- Crimes against minors, elders (65+), dependent adults
- Terasoft (planning to hurt someone)
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Privilege
- Applies to legal proceeding and release of confidential client information
- Every client has right to privilege
- Parent/Guardian ad litem asserts privilege on minor
- If judge asks YES, attorney NO
- Minors hold own privilege but only guardian can waive it
- A deceased person has court order, there has to be a person with legal authority for client info
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Malpractice & Unprofessional Conduct: What can happen
- Lose license/Revoked license(temporary)
- Suspended
- Fines
- Probation
- Lose intern registration
DUI, criminal cases like fraud, disciplinary actions, sexual misconduct (2 years)
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If working with a couple and the male filed a claim, but female didn't...What can you do?
Can testify against because both have to file and sign the claim.
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Malpractice & Unprofessional Conduct: Harshest penalty
- Sexual conduct or intimacy
- Illegal and Unethical
- Has to be outside of 2 years (BBS)
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What is considered Malpractice & Unprofessional Conduct?
- Not practicing in scope of practice
- Misdiagnose client (not getting correct treatment)
- Breach of confidentiality
- Managing a dangerous client
- Not doing mandated reporting
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Malpractice & Unprofessional Conduct: How to avoid getting in trouble
- Abide by laws
- Build good relationships with clients
- Continuing education
- Liability insurance
- Keep excellent records and documentation
- CAMFT membership
- CONSULT!!!
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Therapeutic Duty
- 1. Do NO Harm
- 2. Work in scope of practice
- 3. Assess, diagnose, and treat
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Informed Consent (Umbrella)
- 1. Fees (On the phone before you see them)
- 2. Trainee status and supervisor
- 3. Technology use
- 4. HIPPA (privacy practices)
- 5. Risk/Benefits to treatment (may not meet client expectation, may lead to deeper issues, diagnosis may be on permanent record, improved relationships, learn coping mechanisms)
- 6. Authorization to release information
- 7. Tape of video
- 8. Length of treatment (45-60 minutes)
- 9. Termination policy
- 10. Office policies (cancellation policy, vacations, available on call, communication policies, 911 emergencies)
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Informed Consent (Client Needs)
- Must be verbally and physically gone over
- Client needs to be competent
- Need to understand their treatment
- Need to know what they are getting themselves into and understand
- Need to sign "consent to treatment"
- Need to know Limits of Confidentiality
- Set foundation of trust
- Know what therapists do
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Termination: What to do
- P: Premature Exits (bad fit, financial issues, moving, transportation, disability, legal issues)
- L: Loss (how they feel about leaving)
- A: Anticipated challenges (where they might stumble)
- R: Referrals (places of additional support)
- G: Goals met (positive feedback)
- O: Open door policy (come back anytime)
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Therapeutic Duty
- Assess, diagnose, treat
- Do no harm
- Work in scope of practice
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Crisis: Definition
An event or circumstance that prevents therapy from proceeding until the crisis is stabilized
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Crisis: Characteristics
- Requires active role of therapist regardless of theoretical orientation
- Situation beyond control of individual's resources
- Turning point when things get better/worse
- Interruption in normal psychological state of individual/family unit
- Can be one-time event or accumulation of events over time
- Is client dangerous to themselves, you, others?
- Is child involved?
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Crisis Management: Questions to Ask Yourself
- 1. Is the client dangerous to you?
- 2. Is the client dangerous to self? (Ex: suicidal, substance abuse)
- 3. Is the client dangerous to others? (Ex: homicidal)
- 4. Is the client endangered by others? (Ex: child abuse, spouse/partner abuse, elder/dependent adult abuse)
- 5. How will you assess for the crisis? (QRMOTH)
- 6. How will you manage the crisis?
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Crisis Management: Assessment (QRMOTH)
- Q = Questions (How much do you eat a day?, Do you feel safe at home?, How did you get that bruise?, What does displine look like in your house?)
- R = Referrals/Resources (releases)
- M = Mental Status Exam (Questionnaire helps with DSM diagnosing)
- O = Observations (bruises, cuts, hair, body language, family interactions)
- T = Testing (anxiety, depression, etc.)
- H = History (parent abuse, domestic violence)
- S = Social Support
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Evidence Code Section _____ allows us to break confidentiality
1024
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Preventative Measures that Break Confidentiality
- Clinical consultation with client's other health care providers
- 24 hour watch by family or friends arranged without client's permission
- If no one present → 5150
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What you can do with Evidence Code Section 1024?
- Not mandated to report suicidality
- Patient dangerous to self and others
- Legally allows you to break confidentiality
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WIC (Welfare Institutions Code) 5150
- Call 911 and state you want to initiate 5150
- Involuntary hospitalization
- Last thing you want to do
- 72 hour hold for treatment and evaluation
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10 Major Reasons for Suicide
- Escape from an unbearable situation
- Join a dead loved one
- Gain attention or manipulate
- Avoid punishment for a crime
- To punish self for a crime
- To punish the survivors
- In response to a voice (e.g. Hallucination such as in schizophrenia)
- To have control over when death occurs(e.g. Terminal illness)
- To become a martyr ("She'll be so mad at me & I can't stand that")
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Guidelines for Assessing Suicidal Behavior
- Suicidality is dyadic nature; there is often another person involved
- a. The suicidal person AND the significant other (parents, sibling)
- b. Ask - if you were to kill yourself, who would be most affected by your death? Ask - if you wrote a suicide note, who would you address it to?
- c. Wonder: what has happened recently with the communication between these two people? How can you help restore that communication? (Unless they are hostile or negative)
- Take direct verbal warning seriously
- Pay attention to previous suicide attempts
- Identify client's suffering from depression
- Be alert for feelings of hopelessness
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Assessing Suicdality - TIPM
- T: Thoughts
- I: Intent
- P: Plan
- M: Means
Also ask about personal and family history of suicide attempts
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The suicidal plan may be assessed using SAL
- S: Specific - How is the pla? Get the details of the plan if possible
- A: Availability - Does the person have the means to carry out the pla?
- L: Lethality - What is the likelihood of death by this method?
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Prior attempts: assess for CARL
- C: Chronically factors -
- A: Awareness of lethality -
- R: Rescue
- L: Lethality, what is the actual lethality of the attempt?
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Risk Factors for Suicidality: Intention and History
- Recent/ prior attempts
- Direct or indirect communication of intent
- Extensiveness of plan
- Lethality of means
- Access to means
- Family history
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Risk Factors for Suicidality: Demographics
- Age (teens, middle age, elderly)
- Gender (males more often succeed, females make more attempts)
- Homosexuals (Additional stressors/lack of social supports)
- Race (White)
- Marital Status (Separeted, widowed divorced)
- Social Support (lack of, living alone)
- Employment Status (unemployed, unstable job performance, change in status or performance)
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Risk Factors for Suicidality: Emotional Functioning
- Diagnosis
- Auditory Halluciation
- Recent loss
- Fantasy to reunite with dead loved one
- Stresses
- Poor coping abilities
- Degree of hopelessness
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Goals of Intervention for Suicidality
- 1. Reassurance
- 2. Comfort
- 3. Hope
- 4. Prevention of Suicide
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Interventions for Suicidality
- H: Hooks (future goals, who or what they care about)
- E: Exceptions (When have they not felt this way before?)
- C: Coping strategies (What has worked in the past when they felt hopeless, sad, and lonely?)
- NO HARM CONTRACT!!!
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What to Document with Suicidal Clients
- 1. Statements about suicidal thoughts, plans, and intent
- 2. Past suicide attempts
- 3. Degree of hopelessness
- 3. Acute risk factors (family, alcohol, stresses, support)
- 5. Your judgment about lethality
- 6. Action taken
- 7. Results of action
- 8. Periodical inquiry about suicidal thoughts
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Management of Suicidality: Basics of Increasingly Protective Interventions
- LEAST TO MOST INTRUSIVE
- Refer to a psychiatrist/physician for evaluations
- Maintain communication
- Provide emergency contact info/suicide hotline
- Develop safety plan
- Allow for telephone contact between sessions, as needed
- Increase number of sessions
- Provide 24 hour coverage
- Incorportate family/significant others into therapy
- Involve family/significant other, should a 24 hour coverage become necessary
- Encourage voluntary hospitalization, if necessary
- Breach confidentiality to initiate involuntary hospitalization, if necessary (5150)
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Diabetes and menopause can lead to ______
Depression
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When writing a safety plan with client.....
Client must write and sign that agreement and keep a copy on file
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10 Most Common Errors in Suicide Prevention
- A: Avoidance of strong feelings
- I: Inadequate assessment of suicidal intent
- D: Defensiveness
- S: Superficial reassurance
- I: Insufficient directiveness
- F: Failure to identify the precipitating event
- P: Passivity
- A: Advice giving
- P: Professionalism
- S: Sterotypic responses
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Domestic Violence Statistics
- Prevalence: raped, beaten, stalked, killed by intimate partner than by strangers
- Women are murdered by intimate partners (33%)
- 33% of emergency room visits are made by women experiencing intimate violence
- Such violence in major contributor to homelessness for women
- 20% of pregnant women are abused by their partners during pregnancy
- Violence against women in dating relationships is as common as violence against married women
- Men don't report domestic violence as much
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Cycle of Violence
- Shows a pattern in abusive relationships - 3 phases repeat over and over - pattern escalates over time
- Intergenerational - repeats itself by emerging later in the relationship of people who have experience and witness violence in the home as they grew up
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Victim Personal Safety Plan: If you had perpetrator evicted or are living alone, you may want to:
- Change locks
- Install security system
- Teach children to call the police
- Get children to be picked up from parents or teachers
- Get a lawyer
- Get a restraining order
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Victim Personal Safety Plan: If you are leaving your abuser, ask yourself the following questions:
- When is the safest time to leave? - Go where?
- Comfortable calling police?
- Who can you trust to tell you are leaving?
- How will you travel safely to pick up kids?
- What legal resources will help you feel safer?
- Do you know the # of the local shelter?
- What custody will keep you and the kids safe?
- Should I get a restraining order?
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Victim Personal Safety Plan: If you are staying with you batterer, think about:
- What's the best way to keep you safe in an emergency?
- Who can you call in a crisis?
- Are there signals you can give to kids/neighbors to help call 911?
- If you need to leave, where will you go?
- Know escape routes in house
- Have important paper close (SSN, driver's license, passport, money, keys)
Remember you cannot stop abuser, BUT you can find help
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Clinician Safety (Potentially Dangerous Client)
- Seek consultation
- Don't see client at beginning or end of the day
- Alert other clinicians
- Keep door open and sit by door
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Domestic Violence: Legal and Ethical Issues
- First goal: implement safety plan
- Include extended family in safety plan
- Don't see them together
- Allow victim to implement all of their plans
- NOT MANDATED AND NOT PERMITTED TO REPORT
- Only medical doctors can report
- If domestic violence and child abuse, report child abuse
If we report, BREACH OF CONFIDENTALITY - California penal code 11160(A) - Only medical practitioners who provide medical services for physical conditions
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Distinguish Reporting Domestic Violence VS. Other Mandated Reports
- Victim = Minor/Elder/Dependent Adult
- Child witness only, mandated report depending on effect on minor
- If minor is mentally suffering
- May be mandated to report if effect of observation of DV is significant on child
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4 IMPORTANT FACTS on Domestic Violence
- We don't report
- We create safety plan
- Don't see client as couple
- Can keep secrets?
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Reasonable suspicion
If you suspect child abuse, make a report
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Child Abuse
Abuse to anyone under the age of 18
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Type of Child Abuse
- Physical abuse
- Sexual abuse
- Neglect
- Emotional abuse
- Fetal abuse
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Child Abuse: Physical Abuse
- Non-intentional --> then consult
- Bruises, fracture, burns, etc.
- Willful cruelty and on purpose
- Cultural = gray area
- Intent and how often (IMPORTANT)
Signs: Child flinches, weird clothing, unexplainable bruises/cuts
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Child Abuse: Sexual Abuse
- Luid/Lucivious/Lascivious acts on children (sexual desire)
- Downloading or streaming child porn
- Coerces a minor or suggestions to minor
Signs: Trouble walking/sitting, excessive knowledge of sex for their age, real seductive behavior, avoid uncle/aunt, run away from home, bed wetting, doesn't want to change in front of others, 14 and under has STD, promiscuity, drug use, cutting, self-injury
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Child Abuse: Neglect
Child left uncared for and unsafe
Severe Signs: leaving child alone in car/bathtubs, living in a car, no adequate food/clothing
Signs: not giving home, not being fed, medical conditions not met, smell of urine, low hygiene, dress inappropriately, late for school, noticeable body odor, untreated illnesses, physical injuries,
Latch-key kids and homelessness NOT REPORTABLE
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Child Abuse: Emotional Abuse
OPTIONAL
- Support that child suffering due to emotional abuse
- Hard to prove
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Child Abuse: Fetal Abuse
OPTIONAL
- Woman harming fetus
- Abuse of drugs/alcohol
- Wire hanger abortions
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Management of Abuse
- Most cases, unless suspicion on parent, NOTIFY PARENT
- CAN incorporate child, unless to young, otherwise make report with child and explain process
- Making report does not mean child taken from home
- Parents may be angry and may not come back
- Keep in mind, report to take care of child
- Write out always, child protective services
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Elder Abuse
Abuse to anyone age 65 and older
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Types of Elder Abuse
- Physical abuse
- Isolation
- Neglect
- Financial
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Elder Abuse: Physical Abuse
- Sexual falls under this
- Assault/Abandonment
- Bruises, bed sores, fractures, cuts
- Left alone, family leaves them
- No resources for survival
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Elder Abuse: Isolation
Cuts off visitors, family, and friends
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Elder Abuse: Neglect
- Lack of medication, food
- Not retreating illness
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Elder Abuse: Financial
- Bills not paid
- Fininacnial scams
- Use of info and credit cards
Ex
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Exceptions to Reporting Elder Abuse
- ALL 3 MUST BE PRESENT
- 1. No evidence
- 2. Dementia or any kind of mental illness
- 3.Clinical judgment that the of use did not occur
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Dependent Adult Abuse
Abuse to anyone 18-64
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OMBUDSMAN
Protocol for working n faculty and care for elders
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Procedures for Elder Abuse
- Serious bodily injury
- Call police, OMBUDSMAN, within 2 hours of in-care facility
- If you know elder abuse happening at home, call adult protective services within 2 hours, and written report in 2 days
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