Psychological assessment

Main factors associated with suicidal behavior

General risk assessment in understanding why person might be depressed, & also to point to areas which might be helped, in decreasing risk; assessment to determine risk of suicide in a client.

Sex: Men

Age: 15-24, males 75+, females 45-54, 65+

Depression: hopelessness

Prior History: attempts

Ethanol Abuse: alcohol/drugs

Rational Thinking Loss: psychosis

Support System Loss

Organized Plan

No Significant Other

Sickness: in self or significant others

Rating scale: 1 point each

0-2 keep watch

3-4 send home; call often

5-6 consider hospitalization

7-10 hospitalize

Ex: 

Assent vs. Consent to Treatment

Ethics & law, clinical practice

Consent may only be given by individuals who have reached legal age of consent (in the U.S., typically 18)  

Assent is the agreement of someone not able to give legal consent to participate in the activity

Assent occurs when therapist makes sure child understands therapy process at developmentally appropriate level & have them provide their assent to treatment, or willingness to participate in therapy 

Parents can not force them into therapy

Work with children or adults not capable of giving consent requires the consent of the parent or legal guardian and the assent of the subject

Ex: 

Bartering of Clinical Services

Ethics & clinical practice

Clinician takes payment for services not monetary

Not looked on favorably but may be done if not clinically contraindicated

If bartering is done, terms of bartering should be clearly delineated in written contract

Ex: Tommy could not pay monetarily for his sessions, but was skilled in lawn care. He and his therapist constructed a contract in which he would do landscaping for her yard while she provided therapeutic services.

Basic Purpose of Ethical Practice

Ethics & clinical practice

Primary purpose of ethical practice is to safeguard client's well-being.

Guiding principles of: autonomy, beneficence, nonmaleficence (to not inflict harm intentionally), & justice can assist clinicians in this endeavor.

Should educate professional about sound ethical conduct, be a mechanism for professional accountability, & serve as a catalyst for improving practice

Ex:

Certification

Ethics & Clinical Practice

Statement of confidence from agency that a person is qualified to perform certain job or task

Indicates that individual has certain set of knowledge, skills, or abilities in view of certifying body

Certification given to professional (i.e., therapist) by group of peers as opposed to a governmental agency

Ex: Alicia became approved by an organization to be an Addictions Counselor, thereby receiving certification for that skill.

Confidentiality

Ethics & law in clinical practice

Responsibility of counselor to not reveal any information about client without client’s explicit permission

Counselor may breach confidentiality if someone vulnerable is being abused (child, elderly, etc.), if the client threatens suicide or homicide, or if court ordered to do so

Breaching confidentiality without one of the aforementioned reasons may result in loss of licensure and lawsuits

(Instances in which confidentiality will need to be broken must be disclosed in the informed consent process)

Ex: A therapist is seeing a well-known celebrity but cannot disclose any of the juicy details about her relationships to her friends because that would be breaking confidentiality, unless**

Confidentiality in Group and Marital Counseling

Ethics, law & clinical practice

Confidentiality in group and marital counseling fundamentally different than individual setting

Therapist must still maintain confidentiality outside of this group, there is no guarantee other members of group or marriage will keep information about other parties confidential

Ex: 

Counselor Competency

Ethics & clinical practice

Counselor’s knowledge base and ability.

Practicing without competency or above one’s level of competency is unethical.

Events or stressors in a clinician’s life may at times impair their competency.

Three factors include the knowledge, technical skills, and emotional competence of the clinician.

Ex: Susan found herself reacting negatively to her male clients because of her divorce, and realized that her competency was diminished because of her own personal stressors.

Direct Liability

Legal aspects of counseling practice

In supervisor/supervisee relationship, supervisor is directly liable for any actions on their part which may lead their trainee to make a mistake in clinical practice.

A supervisor is directly liable for things such as giving inappropriate advice to their trainees or allowing their trainees to practice at a higher level than they are competent at.

Ex: Ted was supervising a trainee named Jasmine and he advised her to terminate therapy with a patient who was clearly not ready for termination. Ted is directly liable for this.

Dual/Multiple Relationships

Ethics & clinicial practice

Dual/multiple relationships occur when clinician has another relationship with client besides therapeutic one 

Psychologist is either: concurrently in another relationship with client, concurrently in a relationship with a person closely associated with the client, or promises relationship in the future.

It is best to avoid multiple relationships when possible.

 (Legally, there must be 2 years of separation btw therapy termination with client & beginning a new relationship)

Ex:

Duty to Warn/Protect

Clinical practice & mental health law

Clinician’s duty to warn authorities if a client makes  threat of harm against a 3rd party

Duty to warn refers to a clinician’s responsibility to warn the identified third party that is in imminent danger because of their client’s threat(s).

Tarasoff Case established that warning authorities alone is not enough, the clinican must warn the individual themselves.

Ex:

Empirically-validated Treatments

Ethical clinical practice

Therapies which have well-defined treatment protocol that can be independently replicated & has been supported by research of several independent investigators. 

EST needs evidence in its favor from at least two well-designed, randomized, placebo-controlled clinical trials; many single-case experimental design studies; or a meta-analysis.

ESTs are used by clinicians practicing evidence-based treatments, which is the integration of the best available research with clinical expertise in the context of the patient’s characteristics, culture, and preferences.

Ex:

Ethics

Clinical practice

Standards which govern conduct of professional members

Most skilled professions (including counselors and therapists) have codes of ethics that the members must abide by

Generally, it’s a higher standard than is required by law.

Ex:

Ethical Boundaries in Clinical Practice

Boundaries which limit nature of therapist & client’s interaction in order to protect therapeutic relationship & client’s well-being

Boundaries in clinical practice may involve physical boundaries (proxemics) and areas of discussion that are off limits.

A boundary crossing takes therapist away from  strictly neutral position, but is not harmful in and of itself.

A boundary violation is a harmful boundary crossing.

Ex: (hugging a client or accepting a gift)

Ethnic-sensitive Practice

Ethics & competent clinical practice

Counselor is ethnic-sensitive when they are aware of their client’s culture & ways in which culture may affect presentation of symptoms & views of treatments.

This counselor should also work to achieve greater multicultural competence.

Ex:

Legal Aspects of Informed Consent

Ethics, Law, in clinical practice

3 requirements that must be met for a person to give informed consent: capacity, comprehension, and that it is voluntary. 

Capacity refers to the ability to make rational decisions; comprehension refers to understanding the material presented; and voluntary means that the client is not under any kind of compulsion.

Ex:

Licensure vs. Certification

Certification is given by a group of professionals to a member of their profession based on their performance.

Licensure is required by law and is given by a government-controlled board.

Certification is usually voluntary, while licensure is required by law.

Certification is going above and beyond licensure requirements.

Ex:

Malpractice

Legality in clinical practice

A civil action in which person claims they were injured by member of profession that furnishes skilled services for compensation.

4 things must be proven: that professional had a duty to person claiming malpractice; that they deviated from the standard of care; that the individual claiming malpractice has been damaged; & there is a direct link between the damage they sustained and the deviation the clinician made.

Ex:

Ethics and mental health law

The mental element of a crime & a necessary element of many crimes.

A culpable mental state. Historically, criminal offenses consisted of unlawful conduct and a culpable mental state (were aware of what they were doing, thought about doing it, & then did it). 

Level of criminal intent required for it to be a criminal offense: the purpose of considering mental state is to distinguish between acts that are inadvertent, accidental, or committed by those who are incapable of forming the intent to commit the action AND those acts performed by someone with a "guilty mind”.

Most criminal offenses require person committing act be consciously aware of action & its potential consequences, including:

1.) Purpose (acted in a way to lead to act)

2.) Knowledge (aware certain result would likely follow, general intent)

3.) Recklessness (indifferent to consequences)

4.) Negligence (caused problem that he/she should have been aware of)

Ex:

Morality

Individual’s internal value system for what is right & wrong & what constitutes right & proper conduct

In the same way as it is important for a counselor not to impose their values on their client, it is equally important that they do not impose their morality upon their client.

Ex: A therapist believes that cheating on your girlfriend is wrong, but does not judge his client for cheating or try to convince him not to do it.

Peer Consultation

Ethical clinical practice

Process whereby counselor may consult with professional peers about clients & treatments they're considering

Allows counselors to ascertain that their biases are not influencing their decisions.

Consultation is essential when using a risk management model.

Ex: Carly was seeing a client who was showing signs of a dissociative disorder. Although Carly was trained to handle these disorders, it was her first time treating one, so she chose to use peer consultation with several other therapists to check and see if the treatment she was considering was the standard of care for dissociation.

Privileged Communication

Information that client has told therapist that cannot be divulged to 3rd party in legal proceeding without the consent of the client

Therapist holds privilege of the record, which the client may access at any time, & cannot share information without consent of client. 

Confidentiality may be broken if the client is thinking about suicide or homicide, a vulnerable individual is being abused, or if the therapist is court ordered to release the record.

Ex: A lawyer subpoenaed a client’s record from a therapist, but the therapist would not release it because it is privileged communication.

Pro Bono Service

Ethics & clinical practice

Service that therapist provides for free, sometimes to members of the community who may not be able to afford their services.

Counselors are highly encouraged, & sometimes required, to contribute to their community by providing pro bono services.

Ex: A client came to Tim in need of therapy but could not afford to pay for it. Tim offered to provide four sessions free of charge to the client in the form of pro bono service.

Professionalism

Clinical Practice

How a professional presents themselves.

Includes appropriate dress & proper behavior when interacting with client, & appropriate behavior when in the community. 

One may be unprofessional without necessarily being unethical, but frequently the two are tied together.

Ex: Cindy, an LPC, went out to a bar one night and became significantly intoxicated. She ran into a client and proceeded to dance and fraternize with them in a way that not not reflect professionalism and was also unethical, as she was crossing boundaries, which could be harmful to the therapeutic relationship.

Reporting Child Abuse

Counselors are mandated reporters of child abuse–one of few situations in which confidentiality may, & must, be breached.

Reports must be made within 24 hours or one business day.

Clinicians must report abuse of the elderly, the mentally handicapped, or anyone else that is vulnerable.

Ex: Eric, a 9 year old, came to see his therapist and had suspicious bruises all over his body. When the therapist asked him about them, Eric seemed distraught but would not say where they came from. The therapist brought it to the attention of Eric’s mother, who refused to talk about it. The therapist informed the mother that he had a mandated responsibility to report child abuse, and when the mother stormed out, he called DSS.

Self-monitoring of Ethical Practice

Ethical clinical practice

Counselors should monitor themselves to make sure they are practicing ethically

Counselors should not rely wholly on self-monitoring, but should also use peer consultations & reviews

Relying solely on self-monitoring could result in rationalization & justification for unethical behaviors

Ex: Mary and her husband, Joe, run a counseling practice together, and have for years been engaging in a therapy known as conversion therapy to try to transform homosexuals into heterosexuals. Because they have been relying too much on self-monitoring of ethical practice instead of consultations and supervisions with other peers, they have rationalized their use of this therapy, despite the fact that it is potentially harmful.

Sexual Intimacies with Former Clients

Ethics, Law & clinical practice

Intimacies with current clients are prohibited while sexual intimacies with former clients are allowed 2 years after termination of therapy. 

Therapist cannot end therapy with the promise of a future sexual relationship (constitutes a multiple relationship), and must ensure that there is minimal risk of harm to their former clients.

Ex: Barney ran into a former client, Teresa, three years after terminating therapy, and found her attractive. However, Barney knew that Teresa had some tendencies towards borderline personality disorder, and decided that being sexually intimate with her could be harmful to her.

Tarasoff Case

Mental health law

Landmark case in California in 1970s, Tarasoff vs. University of California, resulted in a clinician’s duty to warn.

A psychologist was treating a patient who made a threat to kill an identifiable party and was unable to commit the patient and the patient killed the third party. 

The victim's family sued; psychologist had a duty to warn/protect, which led to 1976 Tarasoff decision.

Ruling requires that a therapist breach confidentiality in cases where the welfare and safety of a readily identifiable 3rd party is involved.

When a client communicates a threat directed at an identifiable third party to their counselor and the counselor believes that the person is in imminent danger, they must warn the individual directly instead of simply alerting authorities.

Ex: Billy, an unstable individual who his therapist suspected of having a personality disorder, came in for a session and told his therapist he was planning on killing his wife that night. Due to the precedent established by the Tarasoff case, in addition to reporting the threat to authorities, the therapist had a duty to warn and protect the third party.

Treatment of Minors

Ethical, Legality of clinical practice

Parental consent (preferably from both parents) is required for the treatment of individuals under the age of sixteen, the one exception being crisis situations.

Parents have a right to the record of their child unless they sign a waiver giving up that right.

The therapist should ensure that therapy is age appropriate.

Ex: A thirteen year old showed up at Teresa’s office asking for an appointment. After establishing that the child was not in crisis, Teresa explained that she could not see him without his parent’s consent, and gently suggests ways that he might talk to his parents about coming to therapy.

Values in Counseling

Values are beliefs & attitudes that provide direction for everyday living

Counselor should be careful not to impose their values on their clients, but instead to respect their client’s personal values system.

Ex: Linda was seeing a 25 year old single, pregnant woman who was trying to decide whether to have a child or not, and Linda found herself almost discouraging the woman from having the baby. She realized that she was imposing her values (“unwed mothers are immoral”) on her client.

Vicarious Liability

Legal in context of supervisor/supervisee relationship

Supervisor is vicariously liable and legally responsible for any mistakes that their trainees make in their practice.

Despite the fact that it is the trainee’s mistake, the supervisor assumes responsibility for it when they become supervisor of that individual.

Ex: Ned is supervising a trainee who makes a mistake by agreeing to go on a date with a client who they claim is not severe and “could handle it”. Because Ned is supervising the trainee, he is vicariously liable for this mistake and any consequences resulting from the trainee’s decisions.