Ethical, Legal and Relational Risks of Integrating Individual and Couple/Family Work Keith A. Cross, Ph.D., LMFT July 28, 2017
Objectives Participants will be able to identify the ethical risks of combining individual and couple/family counseling. Participants will know the specific State of Arizona statutes and rules that apply when combining individual and couple/family counseling. Participants will be able to identify the potential effects on the client-therapist relationship when combining individual and couple/family counseling. What we will skip: Clinical effectiveness research, model specific recommendations, and benefits
Agenda Introductions Key Definitions Clients vs Consultants Informed Consent Treatment Confidentiality Ethical, Legal, and Relational Dilemmas Case Studies Recommendations Conclusion
Who’s Who? Name What is your professional background/license? Under what ethics code do you practice? In what setting do you practice?
What do you follow? ? Rules ? ? State Statutes ? ? Ethics Code ?
Who is the “client”? Client/Identified patient Couple/Family Need to clarify if there is an IP or if the “system”/couple is the client Consultant/Collateral Contact
Informed Consent The right of the clients to be informed about their therapy and to make autonomous decisions pertaining to it. It is a shared decision-making process in which a practitioner provides adequate information so that a potential client can make an informed decision about participating in the professional relationship. It is both an ethical and legal obligation of the clinician to provide information to clients before they participate in assessment or treatment (CCC&C, 2014). Marriage and family therapists obtain appropriate informed consent to therapy or related procedures (AAMFT Code of Ethics, 2015)
Informed Consent When psychologists… provide assessment, therapy, counseling or consulting services in person or via electronic transmission…they obtain informed consent of the individual or individuals… (APA Ethical Principles of Psychologists and Code of Conduct, 2010) Clients have the freedom to choose whether to enter into or remain in a counseling relationship and need adequate information about the counseling process and the counselor. Counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both counselors and clients. Informed consent is an ongoing part of the counseling process, and counselors appropriately document discussions of informed consent throughout the counseling relationship. (ACA Code of Ethics, 2014)
Informed Consent Informed consent for treatment is “a written document” which must be “dated and signed…before providing treatment to the client AND when a change occurs in” an element in the informed consent… “that might affect the client’s consent for treatment.” (AZBBHE) a . “Purpose of treatment” What might constitute a change in the “purpose of treatment”? b . “ General procedures to be used in treatment, including benefits, limitations, and potential risks” What might constitute a change in the “general procedures to be used”? c . “The client’s right to have the client’s records and all information regarding the client kept confidential and an explanation of the limitations on confidentiality” What might constitute a change in the these “client’s rights”?
Confidentiality Heitler (2001) quote There is also a “middle - ground” approach that argues that counselors should make the decision to accept and hold confidential secrets in accordance with the greatest benefit for the couple and the therapeutic process (Remley & Herlihy, 2005). Bass & Quimbly, 2006 – Maintain secrets on a case by case basis. “The least risky intervention may not always be the most therapeutic .” Sample “Informed Consent Document For Individuals In Couples Counseling” Margolin (1982) stated, “The most difficult predicament for the therapist would be if she or he failed to convey a policy on confidentiality” (p. 792).
Confidentiality IAMFC, Ethical Code, 2011) – “Couple and family counselors inform clients that statements made by a family member to the counselor during an individual counseling, consultation, or collateral contact are to be treated as confidential. Such statements are not disclosed to other family members without the individual’s permission. However, the couple and family counselor should clearly identify the client of counseling, which may be the couple or family system, and inform clients in writing who(m) the identified client is. Couple and family counselors should inform clients that they do not maintain family secrets, collude with some family members against others, or otherwise contribute to dysfunctional family system dynamics. If a client’s refusal to share information from individual contacts interferes with the agreed goals of counseling, the counselor may terminate treatment and refer the client to another counselor.” ACA, AAMFT , APA do not address this issue
Confidentiality ACA Code of Ethics (2014): In couples and family counseling, counselors clearly define who is considered “the client” and discuss expectations and limitations of confidentiality. Counselors seek agreement and document in writing such agreement among all involved parties regarding the confidentiality of information. In the absence of an agreement to the contrary, the couple or family is considered to be the client. Richard Lesley Avoiding Liability Bulletin on No Secrets Policy PRC Policy in Disclosure Statement: “Couples seen as clients maintain that the therapeutic process requires that information shared individually with the client may not remain confidential from the other partner, as the therapeutic process requires open communication between both partners in the safe environment.”
Treatment “ The application by a licensee of one or more therapeutic practice methods to improve, eliminate, or manage a client’s behavioral health issue.” (AZBBHE) At what point does one become a “client” (and therefore need signed informed consent?) DTO/DTS
SO WHAT’S THE BIG DEAL? Ethical, legal and relational considerations BEFORE moving from individual to couple/family or vice versa
Is the clinician competent to treat both individuals and families? Is the presenting problem within the clinician’s scope of practice? What does the AZBBHE, Psych Board, and Codes of Ethics tell us about this issue? Scope of Practice (both licensure laws and ethics codes)
How does the clinician manage information from the original counseling relationship in sessions with the new relationship? Is the information from individual sessions acceptable to discuss in couple/family sessions or is it kept “secret”/confidential)? Can the clinician remember what information was disclosed in 1:1 sessions and not in couple/family sessions? Can the client remember what information was disclosed in 1:1 sessions and not in couple/family sessions? What (if any) are the legal implications of unintentionally disclosing a secret? What does the AZBBHE, Psych Board, and Codes of Ethics tell us about this issue?
How does the clinician maintain the client’s (or clients’) records? If the clinician is conducting ongoing individual counseling concurrently with couple/family counseling, does the clinician maintain one file or separate the cases? What if the individual or couple/family work is short term (i.e. 3-5 sessions)? What if the couple breaks up/divorces and the clinician continues to see one of the individuals? If one file is maintained, and there is a request for information, what is released (and what is not)? What does the AZBBHE, Psych Board, and Codes of Ethics tell us about this issue? AZBBHE re: treatment planning AZBBHE examples: Suaye Anna Valenti, LCSW (Case #2016-0057) Christy Maxley, LPC (Case #2016-0077) Martha Nordin, LPC, LISAC (Case #2015-0067) State of AZ Statutes re: privilege (individual or couple)
What procedure and diagnosis codes are used for third party reimbursement? How to balance V-codes vs. individual diagnoses for couples work? How to determine when to use 90837/90847’s for individual work (i.e. 45 vs. 60 minutes) What does the AZBBHE, Psych Board, and Codes of Ethics tell us about this issue?
APGA Code of Ethics (1961) For giggles…
Do your conclusions about any of these issues change if the shift from individual to couple/family (or vice versa) is temporary or permanent? If you are working with an individual who wants to engage his/her family members in counseling, but you are uncertain of your competence to treat couples/families, are you willing to do the couple/family work if it is one or two sessions? How might this change if they were seeking ongoing/concurrent work? Are you more willing to keep secrets from an individual session if it is a one time meeting? How might this change if they were seeking ongoing/concurrent work? What does the AZBBHE, Psych Board, and Codes of Ethics tell us about this issue?
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