Professional Issues and Practices: Standards of Therapy and Boundary Issues Flashcards
where do boundary issues occur
Issues occur in these intersections between therapist, friend, sexual partner
A boundary issue is a multiple relationship, does not mean that it is bad
how can multiple relationships present
They can be
-Overt and subtle
-Concurrent (at same time) and consecutive (happening one after another)
-Unavoidable and avoidable
what are multiple relationships
Refer to the existence of a social or business relationship with a patient, in addition to the professional relationship
Not every
-Multiple relationship is necessarily harmful
-Contact outside of the office is not necessarily an ethical violation
-E.g. at college counseling, teaching psychoeducation or presenting outside of the therapy room
Potential exceptions to boundary modifications and crossings
explain concurrent or consecutive boundaries
Social or business relationship with patients at same time of professional relationship (concurrent)
-E.g. bartering, teaching and supervision,
Social or business relationship with patients before or after the professional relationship (consecutive)
explain overt or subtle boundaries
Blatantly exploitative (sexual relationships)
-Teaching and being their therapist
Boundaries are weakened by just noticeable gradients of behavior (subtle)
-E.g. talking to people outside of business hours
explain avoidable or unavoidable
“you first” rule
-You try to avoid as much as possible
explain sexual attraction to clients
Very common
Have to consider if it is impacting your ability to treat them
Client is sexually attracted to you
-Of course this will happen, not often do people get a chance to talk about themselves for 50 minutes, not always a sexual thing
explain transference and countertransference with difficult patients
Therapist is a trigger for the patient (transference)
Patient is a trigger for the therapist (countertransference)
Therapist should be aware of what is triggering to them
-Potential areas of vulnerability and conflict
Therapists are a toxic waste dump of their patients
Clients go through stages
-Honeymoon idealization
-Devaluation
-Resistance
-Acting out
how could sexual involvement with a client impact the client
Power differential, you know all the intimate information about them and they know nothing about you
-Not an equal playing field
Therapist is vulnerable in the relationship too, intimate relationship, easy to fall into
10 potential categories of client injury
-Ambivalence
-Guilt
-Emptiness
-Sexual confusion
-Impaired ability to trust
-Confused roles and boundaries
-Emotional lability
-Suppressed rage
-Increased suicide risk
-Cognitive dysfunctions, frequently, in the areas of concentrating and memory and often involving flashbacks, intrusive thoughts, unbidden images, and nightmares
ways therapists sexually exploit patients
Role trading
-Actually trading roles in therapy
Sex therapy
-Talking about how to have sex
As if…
-Svengali
-Drugs
-Rape
-True love
-It just got out of hand
-Time out
-Hold me
therapist risk factors for boundary crossings
-Life crisis
-Employment transition
-Illness
-Loneliness and the impulse to confide
-Idealizing the client
-Self esteem issues
-Problems setting limits
-Denial
why do therapists avoid sexual encounters with clients
-Unethical
-Countertherapeutic/exploitive
Against therapist’s personal values
Therapist already in a committed relationship
Feared censure/loss of reputation
Damaging to therapist
Disrupts handling transference/countertransference
Fear of retaliation by client
Attraction too weak/short lived
Illegal
Self control
Common sense
Miscellaneous
how to handle a client that is a victim of sexual abuse
Approximately 50% of therapists have worked with a client who has been a victim of therapist client sexual involvement
Therapist needs to be aware of reactions
Ethical aspects
-Competence
-Informed consent
-Assessment
-Power and trust
what are some examples of non sexual dual relationships
o Personal/friendship
Social interactions
Business/financial
College/ professional
Supervisor/evaluative
Religious
Collegial or professional plus social
o
Workplace
Psychologists are most likely to view social, business/financial and workplace relationships as ethically problematic
why is boundary crossing so difficult
-Dilemmas will often catch us off guard and unprepared
Can tap into our own most basic needs and strongest desires; vulnerable to fallacies
Need clarity around boundaries and how boundary crossings might be different for each client
Can invoke anxiety and fear
Little guidance in making real world decisions about boundary crossings in our training and treatment protocols
difference between multiple relationship and conflict of interest
Conflict of interest, you are getting some gain from something; multiple relationships just exist
what to consider when analyzing post therapy relationships
therapeutic contact, dynamics of the therapeutic bond, social role issues, therapist motivation
explain therapeutic contact
Formal or identifiable closure or termination process
Time period since termination
-Best practice is 2 years
Specific presenting problem or therapeutic issues
-Clients that have boundary issues or borderline tendencies
Maintenance of confidentiality in the post therapeutic relationships
-Best practice to do what you would do if they were still your therapy client
Foreseeable need for future therapy
explain dynamics of therapeutic bond
-Quality of the therapeutic alliance
-Transference
-Power differential
explain social role issues
-Consider potential problems from dual roles
-Do role expectations differ in therapeutic and post therapeutic relationships
-Does the former client understand these differences
-Can the former client and therapist be equals in this relationship
-Maybe if it was a lot of time ago
explain therapist motivation
-Why does the therapist want to enter this relationship
-Potential consequences to themselves and the client
-Former clients should understand the therapist’s motivation for entering a post therapeutic relationship and that this is not a continuation of the therapeutic relationship
explain vacations
Clear understanding of the availability of the therapist outside of sessions
Therapist availability between sessions
Vacations (extended or short vacations)
-How available should you be on vacation?
-Could direct to leave message and you will call them back, but always call 911 if it is an emergency
Serious illnesses
Adequately and reasonably preparing a client for termination
what to consider with informed consent
The cornerstone of our work and sets up what we do
How do we even get informed consent?
What does it mean that consent is informed?
-They understand what you are saying, can maybe report back to you what they consented to
-Giving copies of things can be helpful
How do we know that the patient understands what consent they are giving?
How does culture impact one’s ability to give informed consent?
-Language barrier, disabilities, cultures seeing the therapist as the expert who might not think they can say no to you
An early way we attempt to establish trust with a client
Autonomy (principle E)
Reoccurring process vs. as static state
Informed consent with working with families or groups
what led to Act 147
Mom was trying to get full custody so she could make sole decisions; had a psychologist to review the report and tried to get father’s custody, but never did
Best practice is to get both parents consent, unless there is sole legal custody
consent age 14-17
Any minor 14+
Parent of a minor less than 18 may consent to voluntary outpatient treatment on behalf of the minor and the minor’s consent is not necessary
-What if a child objects to treatment that a parent has consented to?
-You are still supposed to treat them because it is the parent’s consent
“A minor may not abrogate the consent provide by a parent or legal guardian on the minor’s behalf nor may a parent or legal guardian abrogate consent given by the minor on his or her own behalf”
confidentiality with ages 14-18?
For risk you would definitely tell the parent
Not a hard rule on this, just about best practice and what is reasonable
informed consent with ages 14-18
When obtaining informed consent from the minor document in the record that an informed consent process was conducted, the limits of confidentiality, and that the minor substantially understands the nature and purpose of treatment
What about getting paid?
-Do kids bring the money? Is it automatically charged? Release to talk about billing?
minor consent to treatment law in PA
14+
Or (no matter the child’s age, younger than 14 too)…
-An emergency
-Something immediate and disastrous
-Risk assessment
-Document everything
-Note how long you are going to do it (I can work with you for this amount of time until emergency has passed)
Emancipated
D & A (drug and alcohol facilities)
-Facility may notify a parent but this is not required unless a court order has been obtained
Married
Graduated high school
-Seeing someone under age 18 in college counseling; in PA you do not have to worry about it, in some states you cannot consent, you have to get parents to sign consent as a part of all of their medical documents
Pregnant
Borne a child
things to think about for Release of Records Minors <14
-Married/separated/divorced/never married
-Custody arrangement (formal vs. informal)
-When it is informal, get both parents to consent either way
-Any custody arrangement, interpret as “legal”
Same sex couples
-Can be an issue if the child was not legally adopted by another parent
Insurance and billing
-Parent cannot require to see the record, but can send it to another provider
If a parent consents (14+) parents limited to the following info:
-Symptoms
-Diagnosis
-Meds or other treatment
-Risks/benefits
-Expected results from treatment
Parents may consent to release records and information to the primary care provider if, in the judgment of the minor’s current mental health provider, such a release is not detrimental to the minor
