Professional Issues and Practices: Standards of Therapy and Boundary Issues

Question 1

where do boundary issues occur

Answer 1

Issues occur in these intersections between therapist, friend, sexual partner

A boundary issue is a multiple relationship, does not mean that it is bad

Question 2

how can multiple relationships present

Answer 2

They can be
-Overt and subtle
-Concurrent (at same time) and consecutive (happening one after another)
-Unavoidable and avoidable

Question 3

what are multiple relationships

Answer 3

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

Question 4

explain concurrent or consecutive boundaries

Answer 4

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)

Question 5

explain overt or subtle boundaries

Answer 5

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

Question 6

explain avoidable or unavoidable

Answer 6

“you first” rule
-You try to avoid as much as possible

Question 7

explain sexual attraction to clients

Answer 7

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

Question 8

explain transference and countertransference with difficult patients

Answer 8

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

Question 9

how could sexual involvement with a client impact the client

Answer 9

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

Question 10

10 potential categories of client injury

Answer 10

-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

Question 11

ways therapists sexually exploit patients

Answer 11

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

Question 12

therapist risk factors for boundary crossings

Answer 12

-Life crisis
-Employment transition
-Illness
-Loneliness and the impulse to confide
-Idealizing the client
-Self esteem issues
-Problems setting limits
-Denial

Question 13

why do therapists avoid sexual encounters with clients

Answer 13

-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

Question 14

how to handle a client that is a victim of sexual abuse

Answer 14

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

Question 15

what are some examples of non sexual dual relationships

Answer 15

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

Question 16

why is boundary crossing so difficult

Answer 16

-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

Question 17

difference between multiple relationship and conflict of interest

Answer 17

Conflict of interest, you are getting some gain from something; multiple relationships just exist

Question 18

what to consider when analyzing post therapy relationships

Answer 18

therapeutic contact, dynamics of the therapeutic bond, social role issues, therapist motivation

Question 19

explain therapeutic contact

Answer 19

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

Question 20

explain dynamics of therapeutic bond

Answer 20

-Quality of the therapeutic alliance
-Transference
-Power differential

Question 21

explain social role issues

Answer 21

-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

Question 22

explain therapist motivation

Answer 22

-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

Question 23

explain vacations

Answer 23

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

Question 24

what to consider with informed consent

Answer 24

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

Question 25

what led to Act 147

Answer 25

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

Question 26

consent age 14-17

Answer 26

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”

Question 27

confidentiality with ages 14-18?

Answer 27

For risk you would definitely tell the parent

Not a hard rule on this, just about best practice and what is reasonable

Question 28

informed consent with ages 14-18

Answer 28

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?

Question 29

minor consent to treatment law in PA

Answer 29

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

Question 30

things to think about for Release of Records Minors <14

Answer 30

-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