Class Terms/Concepts (Final) Flashcards
Week 8 - 15 class terms and concepts for the final exam. (49 cards)
Corey Ethical Decision-Making Model
- Identify the problem or dilemma.
- Identify the potential issues involved.
- Review the relevant ethics codes.
- Know the applicable laws and regulations.
- Obtain consultation (for the final, be specific about who you would obtain consultation with!)
- Consider possible and probable courses of action. (THREE for the final).
- Enumerate and consider the possible consequences of various decisions.
- Choose what appears to be the best course of action.
progress notes
required formal clinical record notes that include information about the client’s treatment goals and their progress; ethical-decision making; and crisis management
process notes/psychotherapy notes
not required, but permitted notes that involve a therapist’s note-keeping and are theory-based; these can be subpoenaed because the state of CA does not make a distinction between the two types of notes
CA Health and Safety Code 123130: Client Access to Records
CA law that allows a mental health professional to provide a summary of treatment rather than the complete record. The client must request their records in writing and the MFT must provide within 5 working days or 15 working days for treatment summary.
Treatment summaries should include the client’s presenting concerns, findings from consultations/referrals, reports of diagnostic assessments, diagnosis, treatment plan, the progress of treatment, prognosis, and discharge summary.
If MFT believes records would be harmful to client, can
withhold for 30 working days, but must document this. AND –> client has a right for MFT to forward to another
mental health professional to discuss content with them so long as there is a release of authorization signed
Minimum Summary Information to Include in Informed Consent (CA Health and Safety Code 123130)
o Presenting concerns, relevant history
o Findings from consultations, referrals
o Reports of diagnostic assessments
o Diagnosis
o Treatment Plan
o Progress of Treatment
o Prognosis
o Discharge Summary
Counselor responsibilities regarding documentation
- Clinical – track treatment goals and progress; document standard of care practices.
- Ethical – document scope of practice and competence; ethical decision-making process; review by supervisors to ensure practice is within standard of care.
- Legal – legally required to document comprehensive yet concise representation of client progress (having informed consent is required, it is a therapeutic duty, but the actual material in the informed consent form varies depending on agency).
- Risk management – document clients with danger of harm to self/others, and even more details than you usually would concerning the level of risk, how this risk was assessed, etc. (e.g., antecedents, assessment interventions, consultation, reporting, etc).
CA Health and Safety Code 124260 (2011) - Minors
“[A] minor who is 12 years of age or older may consent to [outpatient] mental health treatment or counseling services if, in the opinion of the attending professional person, the minor is mature enough to participate in therapy intelligently in the mental health treatment or counseling services.”
–> the criteria to determine if client is competent enough to consent for therapy by themselves is the reasonable person standard
–> when a minor consents for treatment, the mental health care provider is not permitted to share records with a parent without the minor’s authorization
–but . . . CA law requires mental health care providers to “involve parent(s) in treatment unless, in the opinion of the professional person who is treating the minor, the involvement would be inappropriate.” –> standard of care = treatment summaries, does not equate to full access to all confidential records
privilege
protection of private information within the context of the legal system –> informs whether or not we have to enter info from therapy into the legal context or we can assert ___
confidentiality
protection of private information within professional relationships i.e., within the therapeutic relationship
CA business and professions code 4982: “It is unprofessional conduct for failure to maintain ____, except as otherwise required or permitted by law, of all information that has been received from a client in confidence during the course of treatment and all information about the client, which is obtained from tests or other means.”
privacy
constitutionally established “zone of ____” [sort of]; control of personal info in PHI and HIPAA; there is an expectation our health info is ____
waive privilege
client authorizes the release of their information
IMPORTANT: the client holds privilege and determines whether or not to waive it
assert privilege
therapist does this when on behalf of the client when the client does not authorize the release of their info –> essentially refuse to disclose any client info
exemptions of privilege
1) client sues therapist (i.e., malpractice suit)
2) client claims psychological damages in civil suit
3) court-order psychological evaluation
4) client-initiated psychological evaluation (to establish competency)
5) child/elder/dependent adult abuse
6) imminent danger to self/others/property
7) minor < 16 years of age victim of crime
Mandated disclosures to breaking confidentiality in CA
1) Tarasoff
2) Reasonable suspicion of abuse
3) Court order
Permitted disclosures to breaking confidentiality in CA
1) client signs waiver authorizing release of info
2) supervision
3) professional consultation
4) threat of harm to self
5) threat of harm to property (technically exemption to privilege)
duty to warn
required to inform law enforcement, and requires breaking confidentiality by definition
duty to warn
required to inform law enforcement, and requires breaking confidentiality by definition
duty to protect
you must protect the victim, but there is a plethora of ways you can do that, and this could potentially not involve breaking confidentiality
Tarasoff case law
-therapist determines client is a serious danger to others
-range of options to discharge duty to protect
-obligation to use “reasonable care” to protect intended victims
-no provision of immunity
Tarasoff statute
-client communicates serious threat of violence to therapist
-duty to warn victim (i.e., reasonably identifiable victims) and law enforcement
-provides immunity ONLY when discharged duty to warn
-addresses provisions for how therapists can get immunity (immunity = follow these instructions in duty to protect, won’t be liable to be sued)
Jensen (2015) - CA Duty to Report
-therapists have a duty to report serious threats of violence to local law enforcement –> civil immunity will be granted to therapists who comply
-goal: remove current or future firearms/weapons from patients who are assessed as a danger to others (regardless of method) –> patients are prohibited from possessing, controlling, purchasing, or receiving weapons for five years
reasonable person standard
likelihood of violence assessed based on therapist’s use of “reasonable degree of skill, knowledge, care ordinarily possessed by members of that speciality under similar circumstances.”
assessment of risk (of harm to others)
therapist reasonably determines that client presents a serious danger of violence to another person(s)
–> serious = risk of real, imminent violence (vs. expression of violence that is not probable)
–> dangerous = serious risk of loss of life OR grave bodily injury (GBI = loss of consciousness, concussion, fracture, wounds requiring sure, loss/impairment of organs, serious disfigurement)
Assessing Risk of Violence: ACTION (Borum & Reddy, 2001)
a systematic, informal way of assessing the risk of harm to others involving the assessment of seven components:
Attitudes (A): does the client believe that violence is justified in these circumstances?
Capacity (C): does the client have the means to carry out the threats? (e.g., access to weapons)
Threshold (T): does the client have a plan, and what is the extent that the client has put the plan into action?
Intent (I): does the client communicate specific vs. general comments that reveal serious harm to others?
Others’ reactions (O): have others encouraged or discouraged client’s hostile reactions?
Noncompliance (N): does the client demonstrate an unwillingness to consider alternatives to violence?
Other factors:
1- history of violence/assault?
2- carried out previous threats?
3- history of mental instability?
4- history of substance abuse?
