Legal & Ethical Issue Midterm

Set of obligations between principle and virtue ethics

Ex: "What am I going to do best for my client?"

focuses on character traits of counselor and no obligatory ideals to which professionals aspire rather than on solving

Code of Ethics

• 1. Educate professionals about good conduct
• 2. Ethical standards provide a mechanism for professional acountability
• 3. Code is catalyst from proving practice generally

Highest standard of thinking

Making sure we can do better things with clients

Free services to a client

Avoiding doing harm

Promote well being of clients

Treat others equally

Make realistic comments, keep promises

Be honest with client

• Dicuss finances (OUTSIDE OF SCOPE)
• Do not make reports to police

• 1. Education
• 2. Training
• 3. Experience

ALSO ASK FOR PERMISSION FROM CLIENT

• Inside Scope of Competence 
• He has his PhD, if he just had LMFT then no because MFT cannot administer tests

• Outside Scope of Competence
• She does not have sufficient training

• Outside Scope of Competence
• Unless he consults and gets more training

• Outside Scope of Practice 
• She can't give medical advice or prescribe medication
• Might be competent

• NO!
• Unless it is harm for others

• Assess, Diagnose, and Treat
• Couples, Individuals, Families, and Children
• Work with relationship issues/Enhance relationships

• "I didn't see that coming..."
• "Oh that breaks my heart..."

Attack the anger

• 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

Clients project onto their therapists past feelings or attitudes they had toward their caregivers or significant people in their lives

• 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

• 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

• 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

• Keep separate folder with "General Medical Condition"
• Must talk about it in the beginning
• Keep current with current medical condition changes

• DUTY TO WARN AND PROTECT
• Danger to others
• Crimes against minors, elders (65+), dependent adults
• Terasoft (planning to hurt someone)

• 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

• Lose license/Revoked license(temporary)
• Suspended
• Fines
• Probation
• Lose intern registration

DUI, criminal cases like fraud, disciplinary actions, sexual misconduct (2 years)

Can testify against because both have to file and sign the claim.

• Sexual conduct or intimacy
• Illegal and Unethical
• Has to be outside of 2 years (BBS)

• Not practicing in scope of practice
• Misdiagnose client (not getting correct treatment)
• Breach of confidentiality
• Managing a dangerous client
• Not doing mandated reporting

• Abide by laws
• Build good relationships with clients
• Continuing education
• Liability insurance
• Keep excellent records and documentation
• CAMFT membership
• CONSULT!!!

• 1. Do NO Harm
• 2. Work in scope of practice
• 3. Assess, diagnose, and treat

• 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)

• 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

• 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)

• Assess, diagnose, treat
• Do no harm
• Work in scope of practice

An event or circumstance that prevents therapy from proceeding until the crisis is stabilized

• 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?

• 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?

• 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

1024

• 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

• Not mandated to report suicidality
• Patient dangerous to self and others
• Legally allows you to break confidentiality

• Call 911 and state you want to initiate 5150
• Involuntary hospitalization
• Last thing you want to do
• 72 hour hold for treatment and evaluation

• 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")

• 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

• T: Thoughts
• I: Intent
• P: Plan
• M: Means

Also ask about personal and family history of suicide attempts

• 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?

• C: Chronically factors - 
• A: Awareness of lethality - 
• R: Rescue
• L: Lethality, what is the actual lethality of the attempt?

• Recent/ prior attempts
• Direct or indirect communication of intent
• Extensiveness of plan
• Lethality of means
• Access to means
• Family history

• 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)

• Diagnosis
• Auditory Halluciation
• Recent loss
• Fantasy to reunite with dead loved one
• Stresses
• Poor coping abilities
• Degree of hopelessness

• 1. Reassurance
• 2. Comfort
• 3. Hope
• 4. Prevention of Suicide

• 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!!!

• 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

• 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)

Depression

Client must write and sign that agreement and keep a copy on file

• 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

• 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

• 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

• 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

• 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?

• 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

• Seek consultation
• Don't see client at beginning or end of the day
• Alert other clinicians
• Keep door open and sit by door

• 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

• 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

• We don't report
• We create safety plan
• Don't see client as couple
• Can keep secrets?

If you suspect child abuse, make a report

Abuse to anyone under the age of 18

• Physical abuse
• Sexual abuse
• Neglect
• Emotional abuse
• Fetal 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

• 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

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

OPTIONAL

• Support that child suffering due to emotional abuse
• Hard to prove

OPTIONAL

• Woman harming fetus
• Abuse of drugs/alcohol
• Wire hanger abortions

• 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

Abuse to anyone age 65 and older

• Physical abuse
• Isolation
• Neglect
• Financial

• Sexual falls under this
• Assault/Abandonment
• Bruises, bed sores, fractures, cuts
• Left alone, family leaves them
• No resources for survival

Cuts off visitors, family, and friends

• Lack of medication, food
• Not retreating illness

• Bills not paid
• Fininacnial scams
• Use of info and credit cards

Ex

• 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

Abuse to anyone 18-64

Protocol for working n faculty and care for elders

• 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