Ethics Part 4

Hi and welcome to Ethics Part 4. If you missed the first couple of parts, you can go back and view those on demand or on our YouTube channel at allceducation. But for today, let's go ahead and get started with part four. Today we're going to review the standard of duty to warn, discuss warning signs of dangerousness to be evaluated and identify ethical issues surrounding involuntary commitment. So duty to warn. This is one of the things that we talk about pretty much in every intro counseling class. We have a duty to warn, protect and predict when at all possible. When a client has communicated to the therapist a serious threat of physical violence against a reasonably identifiable victim or victims. There's a lot of parts to that. The client has to communicate a serious threat, a physical violence to reasonably identifiable victim or victims. So there's a lot of moving pieces in there that you need to consider, which again, as I've said in all the other parts, and I'll continue to say is why you should always have a colleague with whom you can consult. Warning signs of dangerousness. So you have a client who walks in and if they make direct verbal warnings or threats, I'm going to kill my ex wife, I'm going to do harm to my boss, whatever, okay, that's pretty identifiable victim. And you need to use your judgment about whether the person's spouting off just they're angry and ugh, I just want to kill them or if they're really serious, I am going to kill them, I'm going to show up at their office and I'm going to blow them away. Pretty different tone to both of those. When in doubt, consult and make your considerations. If there's a previous history of suicide or homicide attempts, that's a great big warning sign. If they did it once, there's a good chance they may do it again. Clients who have depression or bipolar disorder, especially coming out of that depressive phase of bipolar disorder, once they start getting their energy back a little bit, is the most dangerous time for suicidality. That doesn't mean that they won't commit suicide in a manic phase or a full out depressive phase. So don't just say, well, they're not in that coming out of a depressive phase. You need to take into account clinical judgment, feelings of hopelessness or helplessness. Now many of our clients, when they come to us, are feeling pretty darn hopeless and or helpless. That doesn't mean they're suicidal. You need to evaluate the intensity of that hopelessness and helplessness and we'll talk about that more once we get to the assessment. Interpersonal stressors, loss or separation. So if you have somebody who just lost their job, they just found out they're getting a divorce, their kids told them that they never wanted to see them again, maybe a recent move, maybe they went to jail, There's a lot of different things that can cause interpersonal stressors of loss and separation. Ask yourself if that person's experiencing those, if they feel like a fish out of water just flapping out there by themselves. Not a good sign. Not necessarily a telling sign, for sure. But you take all these things into account and add them up and make a good decision. Other warning signs, if they have severe anxiety or panic attacks, if they're irritable or restless, if they communicate a plan, if there's a sudden change in mood. And this can be going from being agitated to suddenly being very calm. But it can be a lot of other things. If the person's mood just changes and you're like, something's going on with Jim Bob, be aware if there's a sense of a foreshortened future, a lack of future plans. When I used to supervise residential facilities, staff would occasionally call me in the middle of the night and say, Jim Bob is awake, he's up, he's agitated, he's pacing, really depressed. And we would have to go through the assessment about, does he have a plan to kill himself? Does he have the means to kill himself? Has there been any major changes in his social or interpersonal or axis 4 type relationships? And has he started putting his affairs in order? Has there been a substantial change? Maybe Jim Bob gets up every couple of days and paces and is agitated. Well, that's not a huge change. Still want to watch it, but it's not a huge change. And then I would ask if he's got plans for the future. Is he talking about breakfast tomorrow? We don't have to be talking three months from now. If you can get him to talk about what he's going to do for breakfast tomorrow and talking with his therapist when she comes in in the morning, those are some future plans. Now, does that mean that the person is in the clear? No, that means that at that particular point in time, taking all the information we had and adding what I just talked about to it, we would make an assessment at that point about whether the patient needed to be walked over to the crisis stabilization unit, whether he needed to be put on suicide precautions, or whether we just needed to do standard de escalation procedures. Most of the time we would probably implement suicide precautions and up the bed checks to every 10 minutes for the rest of that night, just in case. But it was always a judgment call. Additional risk factors. A history of severe alcohol or drug abuse, especially if they're coming out of that detox period or if they're under the influence, giving away prized possessions or finalizing business affairs. A previous history of psychiatric treatment or hospitalization. A prior diagnosis of a personality disorder. Again, when clients are agitated, when they're feeling hopeless and helpless, when they are really in the mix of everything, it's hard to get an accurate diagnosis at that point in time. You need to see them over the course of a period of time. So you want to look and see. Have they previously been diagnosed with a personality disorder. They may have some of the symptoms right now, but that doesn't mean they've got a personality disorder. So look at historical information. Clients with few social supports. If they don't have anybody to return to, if they don't feel like anybody cares whether they live or die, that's not a good thing. And elderly people and people between the ages of 15 and 24 are at the greatest risk of suicide. One of those things to factor in the back of your head, the suicide assessment. Conduct a thorough assessment. Not just, are you going to kill yourself? Do you have a plan? No. Okay. You really want to ask the client about what's going on in his or her life. What is contributing to that sense of hopelessness and helplessness? Because when we think about suicide, we think about a person who needs the pain to stop. It's intolerable the way it is. So they feel like they have no other options. Talk with them. Talk with them about what they see is the presenting problem. What they see are the solutions, if any, what their future plans are. Create some sort of an action plan, even if it's just to get them through hour to hour. When I worked at the crisis hotline, a lot of times we would talk to people and we would have them call back every hour. If it wasn't a case where we needed to have somebody go over and start involuntary commitment, then we would have them call back every hour and check in. It would get them through the night. A lot of times, the middle of the night is when people start to feel really hopeless and helpless because nobody's awake. There's nobody to talk to. They don't want to call anybody even if they had anybody, so they feel even more isolated and alone. So conduct a thorough assessment. Obtain relevant history and previous treatment records. If the Person's been hospitalized for a suicide attempt or suicidal ideation, if they have been committed for a 72 hour hold, you need those records. You need to know what prompted it. How serious did it end up being? What were the mitigating factors? How long has it been since the person's been stable or since the person was unstable? How long has the person been mentally stable and not suicidal? Get an idea of those things. Talk with the prior treating physician or therapist if you can about what some things were that your staff could do to help that person feel less isolated, hopeless and helpless. Consult with one or more professionals. Here's the case. This is what I've got going on right now. I'm really concerned. What's your opinion? Have people that you can call especially. Well, I won't even say that. Regardless of whether you're outpatient, residential, whatever. Have people that you can call at 10 o' clock at night or 11 o' clock and go, I just got a call from the answering service that blah blah blah. You need to make sure that you've got people that you can bounce ideas off of. Even if that happens to be maybe somebody at the local crisis stabilization Unit. Some CSUs will provide that consultation and go, yeah, that sounds like somebody needs to come in or no, some won't because there's an issue of liability. But discuss the limits of confidentiality with the client when they start treatment, let them know that they can talk about their feelings. But if you have a reasonable belief that there is a threat of harm to themselves or someone else, reasonably identifiable victims, then you have the obligation to ensure the safety of everyone involved. Implement appropriate suicide interventions, whether it be an involuntary hold, more frequent bed checks. If it's a residential, there's a variety of different things that you may need to do and you need to look at your agency's policy and procedure manual to make sure that there's a graduated level of suicide intervention protocols. Provide resources to the client. If you're an outpatient therapist, you may not have on call hours. You may not have services available after 4 or 5pm so if they go into crisis at 8:30 at night, who do they call? Emergency room is not usually all that helpful. I mean if they go there, at least it's a semi safe place to stay, although they can walk out anytime they want. If you have a crisis hotline that they can call, give them the number for the suicide hotline. Anything that you can do to give them additional resources so they don't feel so isolated. Contact authorities or family Members. If the client is at high risk for suicide, if you have a reasonable belief that that person is going to kill themselves or is at risk of killing themselves, then you need to notify appropriate emergency resources. Counselors must exercise the ordinary skill and care of a reasonable professional. I keep using that word, reasonable in doing all of the identifying clients who are likely to be physically harmful to third parties, protecting third parties and clients judged potentially dangerous, and treating those clients who are dangerous up through and including involuntary commitment, if that's what it takes. Involuntary commitment needs to be the least restrictive alternative that's available for that person at that point in time. That means that person, they live alone, maybe out in the woods where they don't have neighbors, they don't have anybody they can call, they have no family nearby, they lost their job, nobody would expect to see them on any particular day, and they are coming out of the depressive phase of a bipolar episode. Of a depressive episode. There's a lot of risk factors there and there's very few mitigators. So if you can't identify a reasonable safety plan and mitigators, then you may need to look at involuntary commitment because there's no one to help support that patient when the pain gets excruciating. Be familiar with your state laws and regulations for voluntary and involuntary commitment. In some states, a licensed mental health professional, licensed mental health counselor can initiate involuntary proceedings. In some states, law enforcement can initiate, although they don't like to. And in some states, you have to call out a special crisis stabilization team to do an assessment and determine whether the person needs involuntary commitment. Know what the procedure is in your state. As soon as you notice the client's condition is deteriorating, consult with colleagues and document that consultation. Document, document, document. Carefully consider what you hope to obtain by recommending commitment. Let me go back to document for a minute. Remember how I said I keep talking about reasonable care and the reasonable professional. Well, if you talked with two other professionals and both of them said, no, this person doesn't need to be committed, then heaven forbid, if the person should commit suicide and you end up getting sued, then you can go back and look and produce those records saying, well, I talked to these other reasonable professionals and we all three agreed. Now, that assumes that you provided them all of the information they needed to make an educated, educated decision. And carefully consider what you hope to obtain by recommending commitment. If you hope to obtain basically just some peace and quiet because this client is constantly in crisis, that's you, not them. If you hope to obtain a sense of safety. Every time somebody says they're suicidal, you want to recommend commitment because you're afraid of the liability. That's not going to work either. You need to carefully consider what your motivations are and make sure that that involuntary commitment, stripping them of their rights for 72 hours, is the least restrictive alternative. Before deciding on commitment, consider other options, including referring a client to another professional for evaluation. If you work in a practice where there's multiple clinicians, that may be really easy to do. If you are working in a practice where you're the only clinician, may be harder. You really don't want to take a client who is professing to be suicidal and say, okay, I need you to drive across town and Dr. Smith will work you in within the next couple of hours to get another assessment. That's not going to work. Okay, try to get another opinion, but try to get that opinion to come to you. Ask yourself how commitment will affect the client's attitudes toward you as the therapist and toward therapy in general. Sometimes it's inevitable. You have to do it because you believe the risk is significant. It may impact, negatively impact the relationship between you and that client. However, if it means you saved that client's life, okay, so they're going to have to find another therapist. Hopefully they will over the period of time that they're in there, once they start feeling better, they'll see that you made the choice that you felt you had to make for their safety. Doesn't always happen. However, we need to do what's in the best interest of the client. Know the procedural steps for involuntary commitment, and ensure that you can produce reasons for your decision. You don't necessarily have to do the Beck Depression Inventory. There are suicide inventories out there. But if you know the risk factors and signs for suicide, if you can identify that a significant number of those risk factors existed and this is the reason that you thought it merited involuntary commitment, if you can articulate that and a reasonable professional reading your records can say, yes, I agree, that would be a reasonable choice, then you're probably going to be okay. Now, moving on from suicide to abuse and neglect. Privilege and confidentiality don't apply in cases of child abuse and neglect or elder abuse and neglect. Again, go over this when the client enrolls in treatment. That way you don't get into treatment and then they start telling you a bunch of stuff and you're like, oh, well, wait a minute, let me let you know that if you tell me that, I'm going to have to report it. Tell them at the beginning, once they divulge something to you, it's advisable to try to work with the patient to empower them to make the report, but also make sure that they understand that you're going to have to make that report if it's clinically appropriate. Every once in a while, it's not appropriate to involve the client, but those are really, really rare. And it's usually best to let the client know before you make that call. Most states provide immunity by law from civil suits that may arise from reporting suspected child abuse and neglect if the report is made in good faith. Now, this is suspected child abuse and neglect, so it's a little bit less stringent than that, involuntary commitment. If you have a really good reason to believe that this is happening like the patient tells you, or you're seeing miscellaneous bruises in various stages of healing, erratic behavior, things that would indicate that there might be substance, not substance abuse, that there might be abuse or neglect, then in most cases the best course of action is to consult document. And then if the end of that consultation, you will probably decide that reporting is the best course of action and that reporting body will take it from there. A lot of times I have made reports and the reporting agency has said, okay, we'll take it under advisement. And then they've closed the case with no further action, and that's their choice. I did what I thought was ethically appropriate to protect the protect the patient, protect the client or the child, or protect the elder. Mandatory reporting laws differ from state to state. I don't know of any states in which a licensed professional is not a mandatory reporter. So here comes a little weird question. If you find out information about abuse and neglect, but it's not from a patient, you happen to be at a playground and you're talking to your girlfriend and she tells you something about abuse and neglect of a child, are you mandated to report? Most people would tell you, yes, you're a licensed person who has come into good information about and you have a reasonable belief that a child is in danger. All right, so moving on to age related cases. Now, this area of ethics and law is constantly evolving. In the 2005 ACA guidelines, they state that counselors may be ethically justified in breaching confidentiality to a third party who is at risk from an infected partner, but you are not obligated to take this action. In many states, it's a felony to take that action. And if you remember back to part one, the difference between ethics and law, law sets that Minimum standard. And if the law says you can't, then you've got a little bit of a wicket to figure out. Under many state laws, therapists who disclose a person's HIV status to an unauthorized third party are subject to criminal charges and malpractice action. Very few states have legal protection against liability for practitioners to waive confidentiality to warn third parties at risk of contracting hiv. So very few states have that same protection afforded you with child abuse and neglect or elder abuse and neglect. If you waive that patient's right to confidentiality and you go and tell their partner, which again goes back to you're probably facing malpractice and felony charges. Be aware of your state rules. Dual relationships. Okay, so we're moving on from flagrant abuse and protection to protecting your clients. Dual relationships are defined as having a multi role relationship with a person. It happens in daily life. But when you're a therapist, you've got to consider some of the things. Some instances that I'm aware of, a supervisor may also go to the same club, church, or 12 step meetings as an employee, as a clinical supervisee, or as a client. Does that mean they can't belong to the same country club? No, not necessarily. However, it does mean that you probably need to have a discussion with your client about how that's going to be handled when you run into each other in these other areas. I've seen instances where a person is a clinical supervisor for licensure and also a work supervisor. Now, this is less sticky. However, there are definitely two distinct motivations when you're talking about clinical supervision versus work supervision therapists. If you're a patient's therapist and you show up to the Girl Scout meeting with your daughter and you look across the room and there's another parent there who happens to be a patient, it can happen, especially in smaller towns. The challenge being in some of these instances there aren't other clubs to belong to. So if you want to belong to one, you have to belong to that one. There aren't other 12 step meetings, there aren't other Girl Scout groups. So you have to make a judgment call about the risk of harm to the patient. The other one that really bothers me a lot, but I see it a lot, is somebody who goes through treatment and then comes back less than two years later, especially bothers me, comes back and works at the same facility and becomes colleagues with those very people who treated him or her. There's just so many ethical issues there that it becomes very, very, very sticky. Ideally, you should never be supervised professionally by somebody who used to be your therap. In order to minimize the risks in a dual or multiple relationship. Maintain healthy boundaries from the beginning. If you happen to be on the same PTA committee with a patient, make sure that patient knows ahead of time that at PTA we talk about pta. If you have to call me for some reason on my home phone is going to be about pta. I'm not going to discuss clinical issues outside the normal business hours when I would discuss normal clinical issues with other people. Be very open about that. In this day and age of Facebook and Twitter and this and that, and I can't even name all the social networking sites, it's also important for patients to understand that if you're in a relationship with them because of a club or maybe you live in the same neighborhood or whatever, then you may be on the same message boards. But again, it's not okay to bring the clinical relationship into it. Nor will you remain willing to talk with the client about any potential problems and conflicts that may arise. The biggest one would be maybe a client saying, well, Susie and John are acting different toward me. What did you tell them about what we talk about in therapy? Even if you didn't tell Susie and John anything, you have sort of the burden of proof that you didn't say anything. So keep those boundaries open. Keep them clear. Better not to have dual relationships at all. Consult with other professionals to resolve any dilemmas. If you feel tension growing. If there's an argument that comes up, whatever the case may be, consult with other professionals. Seek supervision when dual relationships become particularly problematic or the risk for harm is high. Now, if the risk for harm is high, don't get into the dual relationship. There has to be another option. Which brings me to my next one. When necessary, refer clients to another professional. Well, if another professional existed, then there probably shouldn't have been a dual relationship in the first place. When at all possible, do not have outside relationships with clients until they've been out of your care for at least 24 months. So if you're walking into that Girl Scout meeting again or that PTA meeting again, and you see a client that was a client of yours three years ago, it's still a dual relationship. You've got to remember that you know a lot of intimate details about that person. However, it may be more navigable than with somebody who is a present client. Key themes surrounding dual and multiple roles in counseling. It affects virtually all mental health practitioners. Whether you live in New York City or some little Podunk town that has 500 residents. It affects everybody. All professional codes of ethics. Caution of the potential exploitation in dual relationships it's really easy when you've pretty much been handed a manual that says, here are all the person's buttons that you can push. It's easy to accidentally, and I will take the high road and say accidentally push somebody's buttons. Because you have that knowledge. Try to avoid it. Not the pushing buttons. Don't push the buttons. Try to avoid the dual relationships. Not all multiple relationships can be avoided, nor are they necessarily harmful. One of the ones that most often comes up in co occurring treatment is relationships in which a therapist happens to attend the same 12 step meeting as former patients. Is it ideal? No. Is it? Absolutely not. Okay, you got to work it out with the patient. Ideally, you're not going to be in a 12 step meeting with somebody who's an active patient because there's a lot greater chance, a much greater chance for harm there. Multiple role relationships challenge us to monitor ourselves and examine our motivation. One of the problems that may arise in people going to the same 12 step meeting, for example, is the therapist may be less willing to share because they're keeping a guard. Likewise, they can share too much and then there's all kinds of boundary issues. So either way, not the best idea, if at all possible, to avoid some small towns. There's only a couple of meetings, so it's not avoidable. Whenever you think about becoming involved in a dual or multiple relationship, get consultation from a trusted colleague or supervisor. Ask somebody, this is what's going on? I don't see any way to avoid it. Do you? What do you think the potential problems or harm could be from this relationship and how can I mitigate it? The caution for entering into dual or multiple relationships should be for the benefit of our clients or others served rather than to protect ourselves. In determining whether to proceed with dual or multiple relationships, consider whether the potential benefit outweighs the potential harm. It's the responsibility of counselor preparation programs to introduce boundary issues and explore multiple relationship questions. Counselor education programs have the responsibility to develop their own guidelines, policies and procedures for dealing with multiple roles and role conflict in the programs. Sexual involvement with clients I know I've talked about it in every single episode of this particular ethics class. However, unfortunately, people are still making the same issue, making the same mistake. So we'll go over it. It's often committed by persons who with all of the following characteristics, with some or all of the following difficulty with intimacy in their personal lives Professional isolation A need to rescue clients. A need for reassurance about one's attractiveness or substance abuse or addiction of some kind. That can be gambling, that can be sex, that can be alcohol. That can be a variety of things, but basically addictive behaviors often serve to help the person numb the pain. When coping skills fall short, which tell you that the person is not coping with life as life presents itself as effectively as we would hope. Okay, so we're not going to sleep with clients. What about physical contact? Ask yourself, how well do I know the client? If you've never met before, much more than a handshake may be perceived as intrusive or overly sexual. Ask yourself, what makes me think that touch is indicated when a client is crying? When a client gets up to leave. When a client terminates treatment, successfully completes. What may make you think touch is indicated? Could this overture be misinterpreted by the client or the client's family as a sexual overture? If the client goes home and says, you know, something really weird happened today when I was leaving therapy, therapist Sarah came up and gave me this big hug. Their family may go, you know, I have some concerns. Ask yourself, is touching appropriate in the circumstance? And then, as I default to use the mom standard, if your mom were in the room and you did that, would you feel okay about it or would you not do it if mom was in the room? Reasons to not become socially involved with clients. You may not be as confrontive as you need to be with your clients when you know them socially. So if you are members of the same country club and Sally is a patient of yours, and she's been coming, you know, you don't see her much at the club, you know, occasionally in passing and big events, and she's your patient, she's been coming for a couple of months, and she's really got some issues where she's got blinders on and you need to confront those behaviors. But you may question yourself because you don't want it to be uncomfortable when you see her at the club. Probably not a good situation. Your own needs to be liked and accepted may cause you to be less challenging. Well, there you go. Your own needs may be enmeshed with those of your clients to the point objectivity is lost. If you become socially involved and you take on this friend relationship out here, then in the therapy room, you may collude with the patient instead of serving as an impartial third party. If somebody's your current patient getting involved enough where you are socially interacting on a regular basis, again is likely going to be a problem. Sexual contact before two years after termination is unethical. In many states, sexual contact with a patient in is illegal or unethical in perpetuity, which means forever. Therapists, go through your state guidelines and statutes and see if it says two years, five years or in perpetuity before you can engage in a relationship with a client. Harmful effects of relationships with clients 90% 90% of patients who report sexual involvement with a therapist report adverse effects. This ranges from mistrust or deterioration of opposite sex relationships to hospitalization and suicide. As therapists, we're paid to be non judgmental, caring, warm, empathic, perfect, no kidding. But we are not asserting our own needs and our own wants and our own stuff which happens in a normal give take relationship. So it creates this weird dynamic. If you get involved with a client outside of the therapy session, they expect you to still be that way, which most times is not going to happen, which may lead the client to become very agitated or confused. Relationships between therapists and clients are never the fault of the client. Clients very often have projection and transference issues. That's a therapeutic issue. That's not an invitation. The therapist client syndrome is associated with sexual contact between therapists and clients. Bears a striking resemblance to rape trauma syndrome and the battered spouse syndrome. In some states, including Florida, sexual misconduct in a therapeutic relationship is a felony. That legal standard we're not even getting up to wondering whether it's an ethical issue. It's a violation of the law, so. Dealing with Attractions Acknowledge the feelings of attraction to yourself. You may have countertransference issues. It exists. You're human, but acknowledge it and deal with it. Explore the reasons you're attracted to a client. What needs might that client be meeting that you're not attending to in your own business? Seek out consultation or personal therapy. Monitor boundaries by setting clear limits on physical contact, self disclosure and client requests for personal information. This should be with every client, not just ones you're attracted to. If you're unable to resolve your feelings appropriately, you'll need to look at termination and referral because that's definitely less harmful to the client than developing therapist client syndrome. In summary, always assess for suicidal and homicidal ideation. Ensure you have adequate plans and policies to handle ideation or suspected decompensation. And avoid sexual relationships with clients at all costs. And one that's not on here. When in doubt and even when not in doubt, consult. It helps. It really helps because you may not even realize you've got blinders and your colleague may go. Dude, what are you thinking? So consult. Alrighty. CEUs are available for this presentation through allce.com they are NVCC, NAADAC, CADAC, and California Board of Behavioral Sciences approved. This course is also accepted in most states for addictions counselor pre certification credit. Have a wonderful day.