Daily Archives: August 7, 2010

Gifts, Therapy, and Actions @ “The Boundary”

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In my opinion, gift giving within the context of the therapeutic relationship is an exercise in common sense.  None of the ethics codes specifically declare gift exchange as unethical, although it can certainly be unethical if taken to extremes.  I view “appropriate” gift giving as a tool to show appreciation and to advance the therapeutic alliance.  In his analysis of the “spectrum of boundary interventions,” Glass (2003) suggested we use the neutral term “actions at the boundary” instead of “boundary violation or transgression,” thereby designating that no boundary was crossed.  The most appropriate gifts in my opinion are “symbolic” and relatively inexpensive, although I can certainly see situations where even inexpensive gifts are wholly inappropriate (especially if they have sexual connotations).  If I was to give a gift, I would probably lean toward therapy-related educational materials (books, etc).

If presented with a gift, I would likely accept it depending on the situation.  I would take the size and the content of the gift into consideration, never accepting gifts that are too expensive, personal, or provocative.  I would also examine the kind of patient presenting the gift, and make as assessment as to whether they would benefit from its acceptance.  I would also be very cognizant of the context… is it early in treatment, around the holidays, or at the time of termination?  The dynamic meaning of the gift is also a consideration, although it is beyond the scope of this essay.  I would guide the interested reader to the Smolar (2002) article for in depth analysis of dynamic meanings of gifts.

In the case of a child giving a hand-made gift, I would generally speaking accept it and proudly display it.  If it advances the therapeutic alliance, I am all for it!

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Glass, L. L. (2003). The gray areas of boundary crossings and violations. American Journal of Psychotherapy, 57(4), 429-444. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=525045091&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Smolar, A. I. (2002). Reflections on gifts in the therapeutic setting: The gift from patient to therapist. American Journal of Psychotherapy, 56(1), 27-45. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=115179463&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Tarasoff v. Regents of the University of California | “Duty to Warn”

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The case of Tarasoff v. Regents of the University of California (1976) is generally regarded as the leading case regarding the issue of “duty to warn.”  The duty to warn concept implies that we, as mental health professionals, have “the duty to protect third parties from harm” and requires “disclosure of threats of harm to others when the provider has a reasonable basis to believe the threat is real and harm could result.”  Specifically, the California Supreme Court ruled “that psychotherapists who determine, or reasonably should determine, that their patients are likely to be danger to identifiable third parties have a duty to take whatever steps are reasonable necessary to protect the potential victims.”  (King & Kramer, 2008)

The duty to warn mandate does not come without limitations and is always subject to interpretation by the states in which we practice.  For example, in Tedrick v. Community Resource Center, Inc. (2007), the Illinois Supreme Court rejected logic of the Tarasoff judgment determining that mental healthcare providers could not be held liable for failing to protect a non-patient third party.  “The providers, in treating the patient, did not undertake to render services for the wife’s protection and, therefore, owed no duty to protect her from the patient’s violent acts.”  In short, the absence of a relationship with the murdered wife rendered the provider blameless.  (“Case law developments”, 2009)  This is the exception to the rule, however.  Most states recognize the “duty to warn” mandate; most clinicians consider it a best practice even in situations where it is not mandatory.

Regardless of the jurisdiction in which we practice, some level of knowledge regarding risk assessment is required.  The purpose of risk assessment is to prevent violence, not to predict it.  Thus, “risk assessment involves estimating the probability of a future event based on secondary, indicator variables.”  (Hanson, 2009, expression Headnote)  “Dvoskin and Heilbrun (2001) suggest that risk should be separated into three separate components: likelihood (probability), imminence, and severity of outcome.  Probability is best defined by actuarial methods; imminence by patterns of violence, statements, plans and life circumstances; and severity by prior history of violence.”  (Norko & Baranoski, 2008, p. 87)  We can visualize what this more informal assessment of risk might look like through the eyes of a typical business.  Business executives will typically use the following six perspectives to analyze a threat in the workplace… method used to communicate the threat (verbal, nonverbal, written, email, etc), credibility (genuineness), lethality (gun vs. fistfight), process (intentions), specificity (target, time, place, means), and type of threat (direct, conditional, veiled).  (Myer & Casile, 2010)

Although an informal assessment of risk might have better luck predicting the weather, this remains the predominate method used by all mental health professionals today to determine if more formal assessment is needed.  In counseling, this informal method might manifest in some of the following questions… Has the client been violent in the past?  Does the client have the means and a plan to perform future violence?  Is there a specific target or is the target more generalized?  What are the client’s living conditions like?  Does the client use or abuse drugs or alcohol?  Are there any foreseeable events or stressors that might invoke an incident, like a divorce for example?  In short, “risk assessment is a process concerned with a variety of issues- risk for what, when, where, and to whom- not just the mere prediction of future violence.”  (Haggard-Grann, 2007, expression Summary)  If a client is determined to be at an elevated level of risk, more formal assessment may be necessary to qualify and quantify the level of risk.

“In high stakes evaluations, such as civil commitment procedures for sexual offenders, most evaluators now consider structured risk tools to be essential.”  (Hanson, 2009, expression Overview of Risk Assessment Practices)  Given the recent prevalence of school related violence, the assessment of risk in student populations is of increasing interest to school counselors and private mental health practitioners alike.  “School violence may range on a continuum from subtle behaviors (e.g., teasing, name calling, bullying, and other forms of intimidation and harassment) to severe actions, such as physical fights and shootings.”  (Bernes & Bardick, 2007, expression ASSESSMENT OF VIOLENCE RISK)  In their comprehensive review of school risk assessment, Bernes and Bardick (2007) advocate the use of the Structured Assessment of Violence Risk in Youth (SAVRY).  SAVRY is a risk assessment tool composed of 24 items in three risk domains (historical, social/contextual, and individual/clinical factors).

Determining the “seriousness” of a threat is no easy matter.  Although we should continue to informally access risk, it is increasingly important that we use standardized, normalized tests to justify decisions in high risk cases.  This is especially important because there are potential legal and ethical ramifications regardless of which option we choose, action or inaction.  Having good justification, documentation, and logic behind our professional decisions will protect us, and perhaps more importantly our clients, from the adverse effects of poor risk assessment.

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Bernes, K. B., & Bardick, A. D. (2007, Apr). Conducting adolescent violence risk assessments: A framework for school counselors.  Professional School Counseling, 10(4), 419-428. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1291137201&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Case law developments. (2009, Nov/Dec).  Mental and Physical Disability Law Reporter, 33(6), 901-1058. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1983868541&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Haggard-Grann, U. (2007, Summer). Assessing violence risk: A review and clinical recommendations. Journal of Counseling and Development : JCD, 85(3), 294-303. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1296984771&sid=1&Fmt=4&clientId=4683&RQT=309&VName=PQD

Hanson, R. K. (2009, Aug). The psychological assessment of risk for crime and violence. Canadian Psychology, 50(3), 172-183. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2003028881&sid=1&Fmt=4&clientId=4683&RQT=309&VName=PQD

King, C. A., & Kramer, A. C. (2008, Oct). Intervention research with youths at elevated risk for suicide: Meeting the ethical and regulatory challenges of informed consent and assent. Suicide & Life – Threatening Behavior, 38(5), 486-498. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1598147731&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Myer, R. A., & Casile, W. J. (2010, Spring). Threats of violence in the workplace. Organization Development Journal, 28(1), 57-73. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1979164171&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Norko, M. A., & Baranoski, M. V. (2008, Feb). The prediction of violence; Detection of dangerousness. Brief Treatment and Crisis Intervention, 8(1), 73-92. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=16&did=1436942351&SrchMode=1&sid=1&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1271696650&clientId=4683

Confidentiality in the Team Environment

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Although it can surely be a challenge, clients being serviced by a team of professionals are nonetheless entitled to a similar degree of confidentiality as their peers that are being serviced by individuals.  However, because group care requires a team approach, the team needs to share information in order to be effective.  For example, in the case of 24 hour inpatient service, there needs to be an effective communication between and among the shifts to determine if “Jimmy has had a good day.”  This contributes to a level of consistency in care, support, and treatment.

Just as in an individual relationship with a counselor, all staff members have a responsibility to breach confidentiality if the client is a danger to self or others.  So, if Jimmy is experiencing suicidal ideation, it is only reasonable that the staff that works directly with that specific client be made aware of the situation.  Secondly, if we have reason to believe that a child, elderly, or dependent adult has been abused, we should again breach confidentiality as a measure of compliance to mandatory reporting law.  In short, the mandatory reporting rules that apply to us as individual clinicians also apply in a group setting.

In my current position, it is generally understood that “anything said to one staff member is said to all.”  There are literally no secrets.  This policy comes with benefits and limitations.  First and foremost, it prevents us from inadvertently breaching confidentiality that was anticipated by our clients.  As higher functioning developmentally disabled adults, they have agreed to such policy, and have acknowledged that they understand it.  However, I also believe it places limitations on the relationships you are able to effectively build, in part because it pits “staff” against “clients.”  There would likely be situations where an individual client would share sensitive information due to the rapport and level of trust with an individual staff member… but that information would not be shared due to the implications of the policy.  The end result may be that the trusting relationship between individual staff members and a client is diminished, in part or wholly as a result of that policy.

Another implicit policy is that it is acceptable to disclose information “up” but not “out.”  This translates in our ability to share information regarding clients to our supervisors and bosses, but not with other staff that do not regularly interact with the clients themselves.  There are, however, situations where information may need to be shared on a need to know basis… for example, when someone picks up a shift, it is probably wise to let them know not to talk about Jimmy’s mom because she just got in a car accident.  In any event, information is provided on a need to know basis, where appropriate, with the client’s best interest in mind.

In the end, I agree with and support the policy of “what is shared with one staff is shared with all” because it is conducive to a team environment.  While it does place limitations on our ability to leverage individual relationships with clients, the benefits outweigh the limitations.  As a result, if I work in a group or a team environment, I would prefer to work in that “everyone knows everything” situation because I believe it’s what’s best for “Jimmy.”

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