Law and Ethics PSY 623

Do you have patients if you are a therapist trainee?

NO, your supervisor is the one who has patients

The big gulp patient

having intimidating or dangerous clients. the ethics issue is threshold disclosure, meaning that the last minute urgent topics are said as they are leaving. Discretion, usually rare and odd

Dueling supervisors

presenting patient material to two different supervisors with different theoretical approaches is a big mistake, because they give different treatment plans but get what you can from each supervisor in the best interest of the client

Threshold disclosure

When a patient drops information at the very end of the session as they are “walking out the door” expect the unexpected and handle things properly

in CA what is the age of majority? aka no longer legally a minor?

18

What is the present status of HIV/AIDS in regards to the og tarasoff and duty to warm? aka try to infect someone (if petient says they are going to harm someone you are required to do something to stop them from harming someone)

There is no duty to warn

how many hours must you accure to take MFT licensing exam in CA?

3000

in intimate partner violence, is it a mandated report situation for CA therapists?

No only if a child is involved

when can a person in CA call themselves a psychologist?

Psy D or Ph. D.

once I pass my exams, can I start practicing independently?

No

Treatment planning: short term

Crisis intervention, handling the “fires”

Treatment planning: intermediate

Hardest method, need to make yourself unnesisary with the skills taught

Treatment planning: long term

Extended treatment where life skills are taught at a deeper level with the client

What do you base the chunk of therapy on?

Theoretical orientation

Expert witness

Witness that generally enters the scene after it has become a legal issue

Fact or percipient witness

Witness on the case prior to it being a legal issue, generally it is the treating therapist

The five always of ethical intake

CCARQ: clients culture, counter transference, area of competence rule out general medical conditions, and question reported

The five always: client culture

Take into account the background, values, culture, history for ethical consideration

The five always: counter transference

if you cant work with someone because of personal trauma that can be an issue, work through that and remember clients best interest

The five always: area of competence

what are my limitations? In training everything is going to be new. We don't refer, we ask our supervisor for ethical guidance

The five always: rule out general medical conditions or substance use

don't see them unless they have been cleared of medical symptomality

The five always: question reporter

"Is there anything else you would like me to know to help me treat you better?"

Laws

Specific rules of conduct

Statute

actual law, legislative process codified thereafter

Case law

higher courts ruling that becomes president, just as binding as statute

Ethics

general professional guidelines you have to follow, and they can touch on the laws

Four mechanisms holding us accountable

Ethics codes, licensing boards, civil suit of malpractice, and criminal allegations

Mechanism #1

Ethics codes- MFT

Mechanism # 2

Licensing boards-BBS, laws and regulations

Mechanism #3

Civil suit of malpractice, with four requirements

Four requirements for a civil suit of malpractice

• Duty of care

• standard of care

• demonstrable harm

• proximate cause

Civil suit of malpractice requirement: duty of care

(relationships established) you need to make sure the patient is safe, should be established by third session

Civil suit of malpractice requirement: standard of care

In legal terms, the level at which the average, prudent provider in a given community would practice. It is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances​.(what would a reasonably trained therapist do given your circumstances?) includes: ETHICS CODES, STATURE, AND CASE LAW!

Civil suit of malpractice: demonstrable harm

(psychological damage, hard to prove and usually needs witnesses) remedy is money

Civil suit of malpractice: proximate cause

(due to something that the therapist did or failed to do to cause the harm, related to demonstrable harm) only proximate cause before damage. an accident resulted in certain injuries

Mechanism #4

Criminal allegations, involves attorney general action, license gets investigated

Criminal vs. civil law

• criminal: guilt

• civil: liable (no one can be guility of a business lawsuit only liable)

Standard of care

In legal terms, the level at which the average, prudent provider in a given community would practice. It is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances​.

O’Conner vs. Donaldson

The landmark decision is that patients have the right to refuse treatment. Mental health systems act (1980) came out of this: THE RULE OF LEAST RESTRICTIVE TREATMENT. if they can be treated outside the hospital they should not be thrown into a hospital, take steps to try and help them be outside of the hospital and avoid being deinstitutionalized.

NIMBY

“Not in my backyard” distinction for where mental health facilities should be in relation to peoples neighborhoods

6 most important words in liability prevention

Consult, consult, consult, document, document, document

Name the four mechanisms holding us accountable for our work as psychotherapists

Ethics Codes and Committees, Licensing Boards​, Civil Suit of Malpractice, AND Criminal Allegations

Name the four elements of a civil suit of malpractice

duty of care, standard of care, demonstrable harm, and proximate cause

Name the four elements of the standard of care

reasonable therapist, ethics codes, statute, and case law

privacy

suggested by the 4th amendment of the bill of rights (no illegal search and seizure)

confidentiality

an ethics term, an agreements between client and therapist to keep utterances private

privilege

legal term pertains to legal issues such as: going to court, testimony, subpoenas, release of records.

arrangement of the BBS

• actual members: public members (nurses, lawyers, appointed by governor of legislatures, barrier) AND licensed members (appointed by governor or legislatures) they make rulings, write regulations, disciplinary action, etc

• clerical staff: analysts (state employees that read the laws and reg document for the practice of MFT and look into that when they get a complaint and decided disciplinary action based on the law) and laws and regulation documents

disciplinary action types

• disciplinary and public: egregious enough to be made public so that the public can protect themselves, usually on the BBS website or CAMFT (ex. sex with patient, breaches, insurance fraud, failure to keep records)

• non disciplinary and confidential: smaller action, (ex. failure to put license on public document or on office display.)

stipulated agreement

where both parties agree upon stipulations to retain license if there is a violation (aka something that is offered to the violating therapist in order to keep their license)

revocation

complete loss of license (3-5 years to get it back)

revocation-stayed

means revocation revocation did not go into effect but on hold, they need to follow stipulated agreement in order to get rid of, usually placed on probation instead. suspension is likely

surrender

an option for the therapist to not follow through with the process and they can surrender the license

disciplinary action process

1. stipulated agreement

2. revocation

3. revocation-stayed

4. surrender

Tarasoff

Patient Dangerous to Himself or Others: There shall be no monetary liability on the part of, and no cause of action shall arise against, any person who is a psychotherapist as defined in Section 1010 of the Evidence Code in failing to warn of and protect from a patient’s threatened violent behavior or failing to predict and warn of and protect from a patient’s violent behavior except where the patient has (1) communicated to the psychotherapist a (2) serious threat of physical violence against a (3) reasonably identifiable victim or victims.

Requirements for mandated report Civil code 43.92 (a)

• Communicated directly to therapist by patient (or by reliable other for the purpose of advancing the patients therapy)

• serious threat of physical harm is imminent

• reasonable identifiable victim(s)

Steps to take when there is a level of dangerousness in client

- Increase Frequency
- Phone Contact
- Support System
- Medication
- Adjunctive Treatment
- Agreement
- Hospitalization

1983 Hedlund Ruling

duty to protect potential bystanders

1983 Veteran’s Administration: Jablonski v United States ruling

attempt to seek past records (even if they get denied put in the records their attempt)

Ewing v. Goldstein (2004)

• communicated to therapist by patient or immediate family member or reliable other

• FOR the purpose of advancing therapy

SAD PERSONA scale (suicidality)

• S(sex)

• A(age)

• D(depression)

• P(previous attempt)

• E(ethanol abuse, every drug abuse)

• R(rational thinking loss, aka psychotic delusions)

• S(social support lacking)

• O(organized plan)

• N(no significant other) Minor: Negligent parenting

• A(access to means) gun owner, police officer, etc.

• S(sickness) Minor: School problems

Involuntary confinement: Welfare & Institutions Code 5150

• 72 hour hold

• Danger to (1) self, (2) other, (3) gravely disabled

• Needs 1 signature by the person who is the county designate, NOT the therapist

• hospitalization used is for time to evaluate

Involuntary confinement: Welfare & Institutions Code 5250

• 14 day certification

• A “continuing danger to (1) self, or (2) other

• Requires 2 signatures (hospital worker and MD)

Gaslighting

a form of psychological abuse in which false information is presented with the intent of making a victim doubt his or her own memory and perception. It may simply be the denial by an abuser that previous abusive incidents ever occurred, or it could be the staging of bizarre events by the abuser with the intention of disorienting the victim. Psychologist Martha Stout states that sociopaths frequently use gaslighting tactics to make victims doubt their perceptions.

Peck v Counselling Ave of Addison city (arson ruling)

use of arson can be a deadly weapon and MAY require a warning

Which is more dangerous and could possibly be fatal with regard to suicide assessment?​

false negative

“Public policy” with regard to suicidal clients and psychotherapists means the therapist should not be blamed if a client attempts or dies by suicide. Why is this true?​

Clients are responsible for their own actions​
If psychotherapists were blamed for suicidal acts of their patient no one would choose to be a psychotherapist

Rational thinking loss

God told me to jump off a building but told me I will not die doing this

Irrational thinking

Youthful exuberance, I haven’ booked my first commercial yet and I have been in Hollywood 3 weeks!

What is the currently accepted terminology when discussing suicide and suicidal clients?​

Death by suicide

Results of Bellah vs Greenson: does Tarasoff apply to suicide? Why not? What happened in the appellate decision?

• Greenson demurred at TRIAL level ​Asked for dismissal based upon:​ No duty to warn in cases of suicide​, AND Statute of limitations to file had run out​ (Two years)

• When the Bellah TRIAL court dismissed the case for primarily statute of limitation issues, interested parties presented the outcome as if the court meant NOT TO EXTEND Tarasoff to suicide.

• What is the duty?​ MANDATED or PERMITTED to breach.

• Mandated to take steps, consult and document, its on a case by case basis

Importance of Menendez “session” tapes

The appellate panel found that the threats made by the brothers against Oziel during the first two sessions eliminated their legal right to maintain confidentiality. ONCE WE ARE THREATENED, THERAPY ENDS.

When to get consent for consult:

-informed consent: good for length of treatment
-release of information: good for 12 months
-getting consent for consultation: when using identifying information for consultation
-do not need consent: when not using identifying demographics
-standard of care: getting a professional consultation

Death With Dignity​

• Applies to adult with a medically confirmed terminal illness ​

• Decision made solely by terminally ill person​

• Prognosis of less than 6 months to live​

• Capacity to make medical decisions​

• Attending physician refers patient to consulting physician for confirmation (second opinion)

Are suicide assessments evidence based?

The Columbia suicide assessments are not evidence based but it is suitable for assessment for suicidal ideation in clinical settings

Braketing

“Managing personal values so they do not contaminate the counseling process...” “Setting aside personal values that are not in line with the legitimate counseling goals of the client, a skill all counselors need to learn.” suspend personal values without giving them up.

Value Imposition​

Direct attempt to influence client to adopt therapist’s values, attitudes, beliefs, behaviors​. Either actively or passively

Conscience clause

a legislative provision that relieves a person from compliance on religious grounds.(cake refusal person example)

What remedies are available for victims under discrimination law?

Court ordered damages may include a maximum of three times the amount of the victim’s actual damages. (based on standard of care, duty of care, demonstrable harm, and proximate cause)

AIDS and Duty to Warn

• Communicated to therapist by patient

  • Patient’s family member/reliable other​

  • Mistakes are made​

  • Test results are in error​

• Serious threat of physical harm​

  • Imminent danger​

  • “Grave bodily injury”​

  • Transmission is medically unclear​

  • Unsafe sex​

  • Sharing needles​

  • Past exposure versus future danger​

• Identifiable victim ​

  • With a “moment’s reflection”​

  • Is unsafe behavior occurring?​

  • Anonymous contacts?​

  • Is there someone to warn?​

  • Therapists are NOT MEDICAL DOCTORS​

  • Thus, cannot diagnose a medical disorder​

  • Primary defense for NOT “Tarasoffing”

CAMFT – ethics code violations

the most common ethical issues associated with complaints against counselors were dual relationships (24%), incompetence (17%) professional misrepresentation (8%), sexual relationships with clients (7%), breach of confidentiality (5%), inappropriate fee assessments (4%), failure to obtain informed consent (1%), and failure to report abuse (1%).

Rule of “least restrictive treatment”

if they can be treated outside the hospital they should not be thrown into a hospital, take steps to try and help them be outside of the hospital and avoid being deinstitutionalized. Increase session, support system, meds consult, agreement, and adjudicative treatment.

Assessments for dangerousness: suicide, homicide, Tarasoff. Who is most likely to act out dangerously

-Suicide completion rates are 3-4x higher for males than the rate for females (access to deadly weapon methods)
-There is a new figure, 45-55 age seems to be the highest rate for attempting and completed suicide
-54% complete suicide by firearm
-IF they have means to a deadly weapon, tell them that they should store it safely in storage and/or with a person you trust for a temporarily period of time
-Men are more likely to be violent than women

For how long is a release of information good?

12 months

How to do a proper intake

Eight Steps for Effective and Ethical Intake:
-Referral Source​
-Psychiatric History​
-Presenting Problem​
-Financial Situation​
-Theoretical Orientation​
-Level of Competence​
-Legal and Ethical Issues​
-Get Emergency Contact Information​

How to do crisis intervention. What is the goal of CI?

The goal is to to bring patient back to premorbid state (pre crisis) aka restore person to pre crisis functioning
-Assess Treatability
-Establish Rapport and Connection​
-Identify Precipitating Event​
-Determine Area of Impact​
-Formulate Crisis Package​
-Facilitate Ventilation​
-Evaluate Coping Mechanisms​
-Summarize and Anticipatory Planning

What do you do if it IS Tarasoff/Ewing?

warm the victim(s)
notify authorities
not in law but mandated to take steps

What does “take steps” mean?

Increase Frequency
Phone Contact
Support System
Medication
Adjunctive Treatment
Agreement
Hospitalization

CCARQ – what does this stand for? Always use in crisis or emergency situations

• Clients culture

• Counter transference: if you cant work with someone because of personal trauma that can be an issue

• Area of competence: what are my limitations? In training everything is going to be new. We don't refer, we ask our supervisor

• Rule out General medical conditions or substance use (don't see them unless they have been cleared of medical symptomality

• Question Reporter "Is there anything else you would like me to know to help me treat you better?"