Psyc 514 – Ethics and Mental Health Law

Question 1

SAD Persons

Answer 1

The SAD PERSONS scale is an acronym utilized as a mnemonic device. It was first developed as a clinical assessment tool for medical students to determine suicide risk,

S – Sex: 1 if male; 0 if female; (more females attempt, more males succeed)
A – Age: 1 if < 20 or > 44
D – Depression: 1 if depression is present
P – Previous attempt: 1 if present
E –Ethanol abuse: 1 if present
R – Rational thinking loss: 1 if present
S – Social Supports Lacking: 1 if present
O – Organized Plan: 1 if plan is made and lethal
N – No Spouse: 1 if divorced, widowed, separated, or single
S – Sickness: 1 if chronic, debilitating, and severe
0- 2 points: No problems, keep watch
3-4 points: Send Home; Check Frequently
5-6 points: Consider hospitalization
7-10 points: Hospitalize

Example: 30 year old Male comes into therapy, with problems abusing alcohol, he has no friends and is disconnected from his family. He attempted suicide a year ago by ingesting sleeping pills, and is currently unable to think of any reasons to live. His wife died 2 years ago and he has decided he will shoot himself with the gun that he keeps under his bed.
Therapist uses SAD Persons scale to asses suicide: 7 needs to be hospitalized.

Question 2

Assent versus Consent to Treatment

Answer 2

“Informed consent” is the voluntary agreement of an individual, or his or her authorized representative, who has the legal capacity to give consent, and who exercises free power of choice.The individual must have sufficient knowledge and understanding of the nature of therapy, the possible risks and potential benefits, and the requirements of therapy to be able to make an informed decision.

“Assent” is a term used to express willingness to participate in research by persons who are by definition too young to give informed consent but who are old enough to understand the proposed treatment in general, its expected risks and possible benefits, and the activities expected of them as subjects.

Assent by itself is not sufficient, however. If assent is given, informed consent must still be obtained from the subject’s parents or guardian. State laws define who constitutes a “child,” and such definitions dictate whether or not a person can legally consent to participate in a protocol.

Ex: The 9 year old boy gave his verbal assent to begin treatment under the care of the therapist. The therapist made sure to go over treatment with the boy. He then explained further details to his mother and had her fill out the informed consent document.

Question 3

Bartering of clinical services

Answer 3

in the context of clinical practice, bartering of clinical services occurs when a clinician accepts payment for their services that is not monetary. Bartering of clinical services is not looked on favorably but may be done if it is not clinically contraindicated (reason to with-hold treatment patient harm) . If bartering is done, the terms of the bartering should be clearly addressed in a written contract.Bartering is more common with poor clients who seek or need therapy or counseling but do not have the money to pay for it. It is also part of the norm in cultures and communities where bartering is a generally accepted means of compensation and economic exchange

EX: Client could not pay monetarily for his sessions, but was a farmer. He and his therapist constructed a contract in which he would do bring in seasonal produce for each therapeutic session.

Question 4

Basic purpose of ethical practice

Answer 4

in the context of clinical practice, the primary purpose of ethical practice is to safeguard the welfare of the client. The guiding principles of autonomy, beneficience, nonmaleficence, and justice can assist clinicians in this endeavor. Codes of ethics should also educate the professional about sound ethical conduct, be a mechanism for professional accountability, and serve as a catalyst for improving practice.

Ex:Therapist understood the basic purpose of ethical practice: to safeguard the welfare of the client.He made sure to promote and utilize only empirically supported interventions backed up by the appropriate research while treating his clients.

Question 5

Certification

Answer 5

a statement of confidence from an agency that a person is qualified to perform a certain job or task. It indicates that the individual has a certain set of knowledge, skills, or abilities in the view of the certifying body. Certification is given to a professional (i.e. a therapist) by a group of their peers as opposed to by a governmental agency.

EX: After completing a specific training course and passing the test, Alicia became approved by an organization to be an Addictions Counselor, thereby receiving certification for that skill.

Question 6

Confidentiality

Answer 6

in the context of clinical practice, this is the ethical and in some states legal responsibility of a counselor to not reveal any information about a client without that client’s explicit permission. A counselor may breach confidentiality if someone vulnerable is being abused (child, elderly, etc.), if the client threatens suicide or homicide, or if court ordered to do so. Breaching confidentiality without one of the aforementioned reasons may result in loss of license and lawsuits.

EX: A therapist is seeing a well-known celebrity but cannot disclose any of the juicy details about her relationships to her friends because that would be breaking confidentiality.

Question 7

Confidentiality in Group or marital counseling

Answer 7

in the context of clinical practice, confidentiality in group and marital counseling is fundamentally different than in an individual setting. While the therapist must still maintain confidentiality outside of the group, there is no guarantee that other members of the group or marriage will keep information about other parties confidential.

Ex:The therapist is aware that maintaining confidentiality in a group counseling is fundamentally different. The therapist was clear about what happens if a member breaks confidentiality during the first session of group therapy. Explained possible consequences: being removed from the group permanently or being removed from the group for a period of time so that the infraction can be more thoroughly reviewed. Therapist encouraged members to talk about the issues in group if it feels safe enough to do so, and with the therapist privately if it is not.

Question 8

Counselor competency

Answer 8

in the context of clinical practice, this refers to a counselor’s knowledge base and ability. Practicing without competency or above one’s level of competency is unethical. Events or stressors in a clinician’s life may at times impair their competency. Three factors: does the clinician have knowledge, technical skills, and emotional competence. Counselors should be sure to continue education by taking classes and trainings in order to remain competent in an ever-changing field.

EX: Susan found herself reacting negatively to her male clients because of her divorce, and realized that her counselor competency was diminished because of her own personal stressors.

Question 9

Direct liability

Answer 9

in the context of a supervisor/supervisee relationship,If a professional fails to follow acceptable standards of practice and harm to a client results, the professional can be held liable for the harm caused.
Direct liability would be charged when the actions of a supervisor were the cause of harm to a supervisee or a client. A supervisor is directly liable for things such as giving inappropriate advice to their trainees or allowing their trainees to practice at a higher level than they are competent.

EX: Ted was supervising a trainee named Jasmine and he advised her to terminate therapy with a patient who was clearly not ready for termination. As a result, the client attempted suicide and was hospitalized. Ted is directly liable for this.

Question 10

Dual/Multiple relationships

Answer 10

in the context of a therapeutic relationship, dual or multiple relationships occur when a clinician has another relationship with the client besides the therapeutic one. The psychologist is either concurrently in another relationship with the client, concurrently in a relationship with a person closely associated with the client, or promises to enter into a relationship in the future. It is best to avoid multiple relationships when possible.

Ex:The client was a wealthy businessman. Because of his close relationship with his therapist, he proposed that he and the therapist go in on a potentially lucrative deal together. The therapist thought it unethical to enter a dual relationship of this nature with his client, and politely refused to enter into this future relationship with his client.

Question 11

Duty to warn/protect

Answer 11

in the context of clinical practice, the duty to protect refers to a clinician’s duty to inform authorities if one of their clients makes a threat of harm against an individual. Duty to warn refers to a clinician’s responsibility to warn the identified third party that is in imminent danger thanks to their client. The Tarasoff Case established that warning authorities alone is not enough, the clinician must warn the individual themselves.

Ex: Client told the therapist that he was planning on killing his mother that night. He excitedly told the therapist that he was going to shoot her with a gun he bought the other day. Therapist knew it was his duty to warn and protect. He informed local authorities and warned client’s mother.

Question 12

Empirically-validated treatments

Answer 12

these are therapies which have a well-defined treatment protocol that can be independently replicated and has been supported by the research of several independent investigators. In terms of empirical support, an EST needs evidence in its favor from at least two well-designed randomized placebo-controlled clinical trials, many single-case experimental design studies, or a meta-analysis. ESTs are used by clinicians practicing evidence-based treatments, which is the integration of the best available research with clinical expertise in the context of the patient’s characteristics, culture, and preferences.

Ex: Therapist understood the basic purpose of ethical practice: to safeguard the welfare of the client.He made sure to promote and utilize only empirically supported interventions backed up by the appropriate research while treating his clients.Exposure therapy has been found to be an empirically validated treatment for clients with a specific phobia.

Question 13

Ethics

Answer 13

in the context of clinical practice, these are the rules and standards which govern the conduct of professional members. Most skilled professions (including counselors and therapists) have codes of ethics imposed by an external organization that the members must abide by. Generally, it’s a higher standard than is required by law.

The Ethics Code is intended to provide guidance for psychologists and standards of professional conduct

Ethics and morals both relate to “right” and “wrong” conduct. However, ethics refer to the series of rules provided to an individual by an external source. e.g. their profession. Morals refer to an individual’s own principles regarding right and wrong.

Ex: It is very difficult and rather stifling to adhere strictly to the APA code of ethics. Connie is a competent and respected therapist who runs her practice using risk management techniques in order to protect herself from both legal troubles and to prevent any ethical complaints.

Question 14

Ethical boundaries in clinical practice

Answer 14

these are boundaries which limit the nature of the therapist and client’s interaction in order to protect the relationship and the client’s well-being. Boundaries in clinical practice may involve physical boundaries and areas of discussion that are off limits. A boundary crossing takes the therapist away from a strictly neutral position, but is not harmful in and of itself. A boundary violation is a harmful boundary crossing.

Ex: The therapist was aware that sexual contact with a client is a strict boundary violation. On the other hand, every once in a while she knew that it was appropriate and therapeutic to engage in boundary crossing with a client. For example, when dealing with children sometimes it was beneficial in relieving anxiety to get down on the floor and color with the child, or to leave the office and go for a walk.

Question 15

Ethnic-sensitive practice

Answer 15

in the context of clinical practice, a counselor is ethnic-sensitive when they are aware of their client’s culture and the ways in which the culture may affect the presentation of symptoms and the views of treatments. An ethnic-sensitive counselor should also work to achieve greater multicultural competence.

Ex:The hispanic man presented to therapy complaining of physical symptoms such as headaches and chronic back pain. The ethnically sensitive counselor was aware of somatization in hispanics when a psychological disturbance is present. The therapist made sure to screen for depression or anxiety related disorders.

Question 16

Legal aspects of Informed Consent

Answer 16

in the context of clinical practice, there are three requirements that must be met in order for a person to give informed consent: capacity, comprehension, and voluntary. Capacity refers to the ability to make rational decisions; comprehension refers to understanding the material presented; and voluntary means that the client is not under any kind of compulsion.

The informed component of consent typically includes informing clients of the nature and risks of therapy, and possible outcomes and alternative treatments. explaining fees and payment policies, detailing the involvement of third parties, and discussing the limits of confidentiality.

The voluntary component of consent requires psychologists to take steps to ensure that clients’ initial and continuing participation in psychotherapy is not subject to coercion by either the psychologist or others in the clients’ social network.

Informed consent provides legal protection for the therapist.

Ex: The client was only 14 years old and legally not of age to give informed consent. (Legally does not have the capacity to make important decisions) She wanted to participate in therapy (voluntary) and was aware of the nature of the therapy. (Comprehension) She gave her assent and the therapist made sure to give her legal guardian informed consent.

Question 17

Licensure vs. Certification

not done

Answer 17

Certification is a statement of confidence from an agency that a person is qualified to perform a certain job or task. It indicates that the individual has a certain set of knowledge, skills, or abilities in the view of the certifying body. Certification is given to a professional (i.e. a therapist) by a group of their peers as opposed to by a governmental agency. Certification is given by a group of professionals to a member of their profession based on their performance; licensure is required by law and is given by a government-controlled board. Certification is usually voluntary, while licensure is required by law. Certification is going above and beyond licensure requirements.

Ex: The therapist was a licensed professional counselor. She attained a master’s degree in counseling , obtain supervised clinical experience and passed a state licensing exam. She was also certified to provide Applied Behavioral Analysis. After getting her Masters she took a training program and paid a membership to become certified.

Question 18

Malpractice

Answer 18

in the context of clinical practice, this is a civil action in which the person claims they were injured by a member of a profession that furnishes skilled services for compensation. In order to prove malpractice, four things must be proven: that the professional had a duty to the person claiming malpractice, that they deviated from the standard of care, that the individual claiming malpractice has been damaged, and that there is a direct link between the damage they sustained and the deviation the clinician made.

Ex: Therapist was accused of malpractice due to the failure to diagnose and report abuse and neglect which resulted in traumatic brain injury to an adopted child.

Question 19

Morality

Answer 19

this is an individual’s internal values system for what is right and wrong and what constitutes right and proper conduct. In the same way as it is important for a counselor not to impose their values on their client, it is equally important that they do not impose their morality upon their client.

EX: Therapist believes that a husband should not go to a strip club. He does not allow his morals to get in the way of treatment. The therapist does not judge the client and does not try to convince client to stop going to the clubs.

Question 20

Peer consultation

Answer 20

in the context of clinical practice, this is a process whereby a counselor may consult with their professional peers about their clients and the treatments they are considering. It allows counselors to ascertain that their biases are not influencing their decisions. Consultation is essential when using a risk management model.

EX: Carly was seeing a client who was showing signs of a dissociative disorder. Although Carly was trained to handle these disorders, it was her first time treating one, so she chose to use peer consultation with several other therapists to check and see if the treatment she was considering was the standard of care for dissociation.

Question 21

Priveleged communication

Answer 21

information that a client has told a therapist that cannot be divulged to a third party in a legal proceeding without the consent of the client. The therapist holds the privilege of the record, which the client may access at any time, and cannot share the information without the consent of the client. Confidentiality may be broken if the client is thinking about suicide/homicide, a vulnerable individual is being abused, or if the therapist is court ordered to release the record.

A straightforward way for the counselor to assert privilege is to state, “I can neither confirm nor deny that the individual is a client, and I cannot divulge confidential information regarding anyone who is a client.”
EX: a lawyer subpoenaed a client’s record from a therapist, but the therapist would not release it because it is privileged communication. The therapist did not have to respond until the record was court ordered by a judge.

Question 22

Pro Bono service

Answer 22

in the context of clinical practice, pro bono service is service that the therapist provides for free, sometimes to members of the community who may not afford their typical services. Counselors are highly encouraged and sometimes required to contribute to their community by providing pro bono service.

EX: A client came to Tim in need of therapy but could not afford to pay for it. Tim offered to provide four sessions free of charge to the client in the form of pro bono service.

Question 23

Professionalism

Answer 23

this refers to how a professional presents themselves. This includes appropriate dress and proper behavior when interacting with a client, and also encompasses appropriate behavior when in the community. One may be unprofessional without necessarily being unethical, but frequently the two are tied together.

EX: Cindy, an LPC, went out to a bar one night and became significantly intoxicated. She ran into a client and proceeded to dance and fraternize with them in a way that did not reflect professionalism.

Question 24

Reporting child abuse

Answer 24

Reporting child abuse – counselors are mandated reporters of child abuse – it is one of the few situations in which confidentiality may, and must be, breached. Reports must be made within 24 hours or one business day. In addition, clinicians must report abuse of the elderly, the mentally handicapped, or anyone else that is vulnerable.

EX: Eric, a 9 year old, came to see his therapist and had suspicious bruises all over his body. When the therapist asked him about them, Eric seemed distraught but would not say where they came from. The therapist brought it to the attention of Eric’s mother, who refused to talk about it. Therapist informed mother that he had a mandated responsibility to report child abuse, and when the mother stormed out, he called DSS.

Question 25

knowledge base

Answer 25

in the context of clinical practice, knowledge base refers to the knowledge and skills that a clinician has accumulated, which can then be applied to their practice. Practicing without the proper knowledge/skills is practicing without competence, which is unethical and may result in harm to the client. A clinician can continually add to their knowledge base through consulting the latest research, continuing education programs, and peer consultations.

Ex: Therapist went to a weekend training/seminar on domestic violence. She received a certificate of completion and increased her knowledge base.

Question 26

Mens rea (not done)

Answer 26

Level of criminal intent required for a criminal offense
Distinguished between acts that are inadvertent, accidental, and acts committed by a person who was incapable of forming the intent

Mens Rae Refers to the level of criminal intent required for a criminal offense to be prosecuted. Essentially, mens rae (“guilty mind”)
asks the question, “Did the individual have a guilty mind when he/she committed a crime?”

Question 27

Self-monitoring of ethical practice

Answer 27

in the context of clinical practice, counselors should monitor themselves in order to make sure they are practicing ethically. However, counselors should not rely wholly on self-monitoring, but should also make use of peer consultations and reviews. Relying solely on self-monitoring could result in rationalization and justification for unethical behaviors.

EX: Mary and her husband, Joe, run a counseling practice together, and have for years been engaging in a therapy known as conversion therapy to try to transform homosexuals into heterosexuals. Because they have been relying too much on self-monitoring of ethical practice instead of consultations and supervisions with other peers, they have rationalized their use of this therapy, despite the fact that it is harmful and unethical.

Question 28

Sexual intimacies with former clients

Answer 28

in the context of clinical practice, intimacies with current clients are prohibited while sexual intimacies with former clients are allowed two years after the termination of therapy. However, the therapist cannot end therapy with the promise of a future sexual relationship (constitutes a multiple relationship), and must ensure that there is minimal risk of harm to their former clients.

EX: Barney ran into a former client, Teresa, three years after terminating therapy, and found her attractive. However, Barney knew that Teresa had some tendencies towards borderline personality disorder, and decided that being sexually intimate with her could be harmful to her.

Question 29

Tarasoff case

Answer 29

a landmark case in California in the 1970s, Tarasoff v. University of California resulted in a clinician’s duty to warn. When a client communicates a threat to an identifiable third party to their counselor and the counselor believes that the person is in imminent danger, they must warn the individual directly instead of simply alerting the authorities.

EX: Billy, an unstable individual who his therapist suspected of having a personality disorder, came in for a session and told his therapist he was planning on killing his wife that night. Due to the precedent established by the Tarasoff case, the therapist called his wife to warn her of her husband’s plan.

Question 30

Treatment of minors

Answer 30

in the context of clinical practice, parental consent (preferably from both parents) is required for the treatment of individuals under the age of sixteen, the one exception being crisis situations. The parents have the right to the record of their child unless they sign a waiver giving up that right. The therapist should ensure that therapy is age appropriate.

EX: A thirteen year old showed up at Teresa’s office asking for an appointment. After establishing that the child was not in crisis, Teresa explained that she could not see him without his parent’s consent, and gently suggests ways that he might talk to his parents about coming to therapy.

Question 31

Values in counseling

Answer 31

in the context of clinical practice, values are beliefs and attitudes that provide direction for everyday living. A counselor should be careful not to impose their values on their clients, but instead to respect their client’s personal values system.

EX: Linda was seeing a 25 year old single woman who was trying to decide whether to have a child or not, and Linda found herself almost discouraging the woman from having the baby. She realized that she was imposing her values (“unwed mothers are immoral”) on her client.

Question 32

Vicarious liability

Answer 32

in the context of a supervisor/supervisee relationship, the supervisor is vicariously liable and legally responsible for any mistakes that their trainees make in their practice. Despite the fact that it is the trainee’s mistake, the supervisor assumes responsibility for it when they become a supervisor of that individual.

EX: Ned is supervising a trainee who makes a mistake by agreeing to go on a date with a client who they claim is not severe and “could handle it.” Because Ned is supervising the trainee, he is vicariously liable for this mistake.