TDC: MFT Law & Ethics Exam

Standard of Care

Overarching construct that defines the usual and customary standards of standard practice.

Overarching guide to make decisions.

NOT a standard of perfection - it's a minimum standard.

4 Elements of Standard of Care

1. Statutes: Things that are in the business code.

Ex: keeping records, mandates/laws, posting license, etc.

2. Licensing Board Regulations

Ex: CEUs for relicensing

3. Ethical Codes

4. Consensus of Professional

Ex: lawsuits

Scope of Practice

Procedures, actions, and processes that are permitted for an individual license in any given field.

Depends on legal standard and is defined by business and professional codes that dictate what each license is allowed to do.

Scope of Practice Violations

Psychotherapy (YES)

Prescribing medication (NO)

Scope of Competence

Defines the area of practice within a professional field in which an individual is proficient to work.

Ethical:

- Your area/skillset

- Defined by the individual (assess skills)

- Most people come in with a limited scope of competence that grows overtime.

Scope of Competence Violations

Working with an individual/population you have no experience working with.

Ex: Working with someone with DV with 0 experience.

Expanding Scope of Competence

Through trainings, guidance, and supervision.

Self Determination/Patient Autonomy

Supporting clients in making their own decisions and promoting agency.

Ex: clients can discontinue treatment at any time.

Self Determination/Patient Autonomy Exception

Safety

- SI

- HI

- Are they able to care for themselves?

Treatment Goals

Starting where the client feels comfortable.

Decision Making

Being able to continue or discontinue treatment at any time.

Informed Consent

When individuals seek treatment, they have a right to know in advance what procedures will be used, relevant facts, and risks involved.

Failure to review = Failure to meet standard of care

Informed Consent Essential Elements

Legal Requirement

- Fees for service: cost

- License status and posted in office

- Technology utilization

- Business name and owner name

- HIPAA: notice of privacy practice

Standard of Care

- Limits of confidentiality/mandated reporting

- Risks and benefits of treatment (feeling worse at the beginning of treatment / couples: could lead to breaking up)

- Alternative treatment methods: medication, acupuncture, nutrition, hypnotherapy

- Cancellation policy

- Billing

- Communication/crisis/frequency

- Background of therapist

- Define who the client is

Informed Consent Issues with Minors

Must be signed

*12 or OLDER: can consent to their own treatment IF they are mature enough to do so and if there is reason to not include parent/guardian.

Ex: A minor wants therapy but parents won't allow for treatment 

Informed Consent with Minors (Signing Consent)

Signed by whoever consents to treatment.

- Married Parents + Never Married Parents: Either/Or can sign

- Divorced: Check custody agreement (whoever has legal custody NOT physical custody)

- Legal Guardian: Legal guardian can sign

- Caregiver: If parents are MIA and another caregiver is providing care, they must sign a caregiver affidavit

- Foster Care: Lawyer can consent unless issued a minute order for social worker/foster parent to consent

- Court Order for treatment

Informed Consent for Couples, Families, and Groups

- No secret policy: Addresses the possibility of somebody contacting you outside of treatment with information about the dynamic of the couple/family.

- Groups: therapists have legal requirement to maintain confidentiality but members do not.

- Document if individual refuses to sign consent.

Confidentiality

Legal & ethical requirement that restricts volunteering information about clients.

Limits of Confidentiality

Mandated:

- Child Abuse/Neglect

- Elder/Dependent Adult Abuse/Neglect

- Danger to Others

- Signs an ROI to speak to someone else

- Search of Office

- Court Order or subpoena by judge

- Client data & coroners investigation

- Patriot Act

Allowed Situations:

- Danger to Self / SI (If 5150 is issued)

- Notifying parent when there is danger

- When coordination of care is needed for discharge planning

- Determining responsibility of payment

- Crime against a therapist

HIV & AIDS

Maintain confidentiality as it is a protected status.

Privilege

Client's legal right to not have confidential information revealed during a legal proceeding.

Who Hold Privilege?

- Always initially the client.

- Couple or Family: All members of treatment unit.

- Minors: Court appointed guardian or guardian ad litem (Parent or relative). *Assert privilege and confirm who holds it.

- Conservator: Conservator

- Deceased: Whoever the court appoints

10 Exceptions to Privilege

1. If a client introduces their emotional condition into a legal proceeding.

Ex: Client who has been sexually assaulted and suing for emotional distress.

2. If a client treats confidential information as not confidential.

Ex: Client who is famous and shares they were sexually assaulted on national tv.

3. If there is a breach of duty.

Ex: Client sues therapist for malpractice/therapist sues for nonpayment.

4. If a therapist has been appointed by a court to examine for court proceeding.

Ex: To determine if client is mentally capable of standing trial.

5. If a client seeks psychotherapy with the intention of committing a crime/escaping punishment.

Ex: Using therapy to get better at lying or covering tracks.

6. If a client (under 16) has been a victim of a crime.

Ex: Extortion, rape, statutory rape.

7. When a psychotherapist has reasonable cause to believe that they are DTS/DTO/Property.

Ex: Property Damage + Emotional Condition

Ex: Mania/Psychosis + Property Damage

8. If a coroner request information during an investigation.

9. When being asked to determine if a client is insane for court.

Ex: Not guilty due to insanity

10. Determining if they are incompetent.

Responding to Subpoenas

Judge = Turn over records

Lawyer = Assert privilege

Child Abuse & Neglect

Reasonable Suspicion: File a phone report immediately and written report within 36 hours.

Child Abuse: Signs of Abuse and Neglect

- Physical: bruising, burn, broken bones, cuts

- If reluctant to share with you.

- If the story doesn't add up.

- If abuse is out of state, file in California

- Medical Neglect: Sick (cough/injured) and not following up

- Sexual Abuse: Anything with a minor, child pornography, sexting (all without consent)

Consensual Sex

- 13 y.o. + 13 y.o. = confidential

- 13 y.o. + Older = mandated report

- 21 y.o. + 16 y.o. = confidential

- 21 y.o. + 15 y.o./younger = mandated report

Dependent Adult & Elder Abuse

Reasonable Suspicion: Report immediately and written report within 2 business days.

Dependent Adult

- Anyone ages 18-64

- Needs physical, mental, financial limitation that restricts their ability to carry out normal ADL's or be able to protect themselves or their rights.

*Incapable of living independently.

Types of Elder/Dependent Adult Abuse

- Physical: Assault, physical restraints, chemical restraints, deprivation of food/water, sexual abuse/assault.

- Abandonment: If the individual caring for the person willfully withdraws care.

- Isolation: Restricting social contact (Ex: mail, not allowed to see family, no access to phone).

- Neglect: If basic hygiene is not supported

- Medical Neglect: Not taken to the doctor.

- Self-Neglect: Living alone and not caring for themselves.

- Financial Abuse: If finances are taken advantage of.

- Abduction: Taken elsewhere against their will.

- Emotional Abuse (optional): Harms and endangers emotional wellbeing.

Where to Report Elder/Dependent Adult Abuse

- APS: If not living in a facility (written = APS)

- Law Enforcement: If living in a facility (written = law enforcement and ombudsman office)

Duty to Protect - Danger to Others

- Surpasses confidentiality

- Legal obligation to protect individuals from possible violence.

- Tarasoff: Duty to protect when a client or credible 3rd party communicates that a client has a serious threat and plan of physical violence and victim is identifiable.

- Notify police and potential victim.

Duty to Protect - Danger to Self

- Assessing for SI: Take appropriate measures to assess. Assess for level of risk and intervene accordingly.

* Allowed but not mandated to break confidentiality.

Signs of SI

- Hopelessness

- Statements that imply SI history

- Assessing for possible self harm

- Assessing for plan/means if endorsing SI

- Removing plan/means

Involuntary Hold

- Most extreme intervention

- If client has a plan and access to means.

Preventive Measures for SI

- No harm contract

- Creating a safety plan

- Increase contact between sessions

- Activate support system

- Psychiatry referral

*Document SI, consult, and document consultation.

Domestic Violence

- Confidentiality: Not a mandated report unless children are involved.

Ex: If DV causes the child unjustifiable mental suffering = report

Ex: If child is harmed = report

Ex: When one of the victims is 65+ = elder abuse report

- Provide resources when DV is disclosed.

- No couple therapy.

Conservatorship

Used for individuals with a psychiatric disorder so severe that it prevents them from providing their most basic needs (food, clothing, shelter).

- Conservator can authorize treatment

- Conservator cannot force conservatee to receive treatment if they don't want it

- Conservatee has a right to confidentiality

Therapy Records

Maintaining therapy records is both legal and ethical

- Adult: Keep records 7 years after date of termination

- Minor: Keep records 7 years after they turn 18

Where to Keep Therapy Records

Keep therapy records in a secure location that's locked, not accessible, and protected under a password (computer).

What to Keep in Therapy Records

- Chief Complaint

- Clinical History

- Consult Findings

- Referrals

- Psychological Testing + Results

- Documentation of Informed Consent

- Treatment Plan + Progress

- ROI

- Dates of Therapy

- Session Start and Stop Time

- Insurance Information

- Emergency Contacts

- Crisis + Detailed Documentation

Who Owns Records

- Private Practice: Therapist

- Agency Setting: Agency

If Therapy Records are Requested

- 5 days to inspect records

- 10 days to provide treatment summary

- 15 days to release copy of records

If therapist refuses access due to risk of detrimental consequences for the client if they see the records:

- Therapist must document the date of request, specific detrimental consequences, inform client request was received and denied, inform client of right to permit another licensed health professional to review.

Adding an Addendum

Client can add up to 250 words if they feel something in the record is missing.

Releasing Records

- Font: 14 point

- ROI needs to be in client's handwriting

- ROI needs to illustrate what can be discussed

- ROI needs an end date

- Notification of client's right to authorization

- If you're on the receiving end of the release, you don't need a new one unless the focus is too narrow

Professional Will

What can be done in the event that something happens to the therapist.

Professional Will: Continuity of Care

Designated licensed therapist who will execute the will and will oversee records and referral for clients.

Professional Will: Bridge Therapists

Colleagues to handle transitions and a known place where the professional will is available that will include information regarding: location, procedures, files, billing and transitions for all clients.

HIPAA

Health Insurance Portability Accountability Act

- Purpose: To create standard medical forms, procedures, and processes of billing and paying for patient care easier.

- Goal: To reduce heath costs + more privacy/confidentiality/patient rights when sharing information.

Who Must Comply with HIPAA

- If you use electronic transactions that go to third party payers.

- Once a HIPAA provider, always a HIPAA provider

Medical/Psychotherapy Records vs. Psychotherapy Notes

- Medical/Psychotherapy Records: The bare minimum of treatment record: diagnosis, treatment plan, start time/end time, interventions, progress notes on symptom change.

- Psychotherapy Notes: Content of client conversation, secrets, specifics, own reflections, case conceptualization, countertransference.

Insurance

- Insurance will only reimburse for medical necessity

- If insurance denies a claim, therapist needs to advocate on behalf of the client.

Insurance - Payment

- Fees (who is responsible?)

- Fraud

- Diagnosis

- Inform insurance of waiving co-pay/change of rate

- Illegal/Unethical to increase fee because they have insurance

Insurance - What Information is Released?

- Diagnosis

- Frequency of visit

- Quality assurance for review

Insurance - Employee Assistance Program (EAP)

- Links to short term support for improvement in the workplace

- Talk about sessions are surrounding productivity at work + short term resources

- Sharing information with EAP and not entirely confidential

Advertising

- License Number

- License Designation

- Present yourself accurately and no claims about guaranteeing expectations of treatment

- Testimonials

Telemedicine

- Providing therapy through phone, instant messaging, emails, and video.

- Review informed consent with client, verbal consent is okay

- Review issues of crisis in informed consent

- Talk about what happens when technology goes down

- Only treat clients within jurisdiction

Managing Fees

- Ethical and legal requirement

- Fees must be discussed prior to commencement of therapy

- Determine client's ability to pay the fees

- If you lower the fee, you're committing to the lower fee

- If you raise the fee, you have to give client notice

- Identify who is responsible for payment

- Give ample notice before fee change

- Non Payment of Fees: you can submit to a collection agency.

- Bartering: only acceptable if it's common practice locally and initiated by client

Referrals

When to refer:

- Anytime it's out of scope of practice

- Scope of competence

- When they can't afford your fee and you have to deny therapy

- When terminating with clients (especially prematurely)

- When a client is not making progress

Misc:

- No payment for referring and receiving referrals

- Provide referrals for DV cases in case of a crisis

- When giving/receiving referrals, document it

- Refrain from seeing someone who sees another therapist

Boundaries

- Therapist needs to determine the relationship and hold the boundary

- Discuss session length, office policies, and availability

- Therapists should not engage with clients on social media

- No sexual conduct with clients

- Gift os low monetary value but emotional value can be taken into account

Boundary Violation vs. Boundary Crossing

Boundary Violation: crossing boundaries when it's clinically inappropriate

- Ex: Dinner with a client without clinician justification

- Ex: Client calling multiple times

Boundary Crossing: crossing boundaries when it's clinically appropriate

- Ex: attending same church/kids going to same school

- Ex: going to lunch with an anorexic client

- Ex: attending a graduation

Dual Relationships

Avoidable:

- Hiring clients to work for you

- Being close personal friends

- Friends with someone who wants you to treat their family/close friend

- Never borrow or loan money

Unavoidable:

- Same school community

- Going to church together

Acceptable:

- Instructor & therapy: always discuss implications

Countertransference/Therapist Impairment

- Sexual attraction, extreme aversion, feelings of dislike

- Therapist's responsibility to manage

- Values Conflict: when the clients presenting problem conflicts with their values, seek consultation

- Therapist Impairment: take into account the therapist's own mental health issues that arise (seek therapy)

- If the therapist is incapacitated in some way

Issues with Colleagues

- If you find out a therapist is acting illegally and unethically: 1. Confront & 2. Make a report to BBS Ethics Committee

- If you learn that a therapist engaged in sexual activity with a client, provide the client with Professional Therapy Never Includes Sexual Behavior pamphlet, discuss options with them, and maintain confidentiality (except if it's a child, then report to CPS)

Consultation/Collaboration

- Collaboration: when a client is referred by another healthcare provider

- When to consult: Out of scope of competence, DV, SI, child abuse, reasonable suspicion & with people who who are expects in the case.

- No ROI needed unless information can be deciphered

Recording/Observation/Research

Specific informed consent is needed, including:

- It can be revoked at any time

- What happens with their information

- Confidentiality will be ensured

Supervision

- Engaging in a relationship with the supervisor holds the boundaries

- Supervisor agreement is made

- Supervisees are employees and know mandated reporting obligations

- Supervisor's BBS and information must be listed

- Client signs form acknowledging that therapist is receiving supervision

- Dual Relationship: can have other relationships with supervisor relationship ends

- Supervisors supervise in scope of competence

Cultural Competency

- Therapists must have knowledge and actively strive to learn about the diverse cultural backgrounds of clients

- Avoid stereotyping and assuming

- Find out from clients how they make sense of their cultural experience

- Informed consent available in their language

- Provide services only if you're competent in that language

- Crisis always overtakes cultural exploration

Termination

- Have discussed termination and termination process at the beginning of therapy as part of the informed consent

- Inappropriate to terminate a client in a crisis state

- Reasons for Termination: stops paying fees, if a client is not making progress/benefiting from treatment, if a therapist is not capable of providing treatment, ethical concerns

- Document reasons for termination + referrals/plans

- Don't keep seeing a client for the money if they are better and no longer meet medical necessity

- Acknowledge a couple sessions prior to termination to process and support self determination of client even if you disagree