These have been had years! . We are facing a pandemic, social unrest, violence against people of color, and an armed insurrection in the Capitol building. Many therapists are feeling stressed, having to switch to online therapy, perhaps while home-schooling their children. We may be feeling burnt-out, depressed, overwhelmed.

Many of us have lost family members, colleagues, friends. These are hard times. For most of the past two years, we couldn't socialize, do any hugging outside of our "social pods" (unless you live alone, and then you may be experiencing "skin hunger.") Restaurants were closed, you couldn't go to the gym, or get your hair cut. And you still have to pay your bills, complete your CEs, and maintain the legal and ethical obligations of the profession.

Uncertainty reigns. Some parts of the world are reopening borders, others not. Wearing a mask or not can vary town to town, county to county. No one knows what is next, yet we as therapists often have to treat anxiety and depression when we ourselves are anxious and depressed. The only certainty is uncertainty. And this is why, perhaps more than ever, we must focus on self-care, and having a strong moral center. If nothing else, we must live our own best lives, so that we can treat others.

As a licensed therapist, I took no oath when I received my license to practice.  Professional mental health therapists swear nothing. Doctors have the Hippocratic oath, which, contrary to popular belief, does not start with, or even include the phrase,  “First, do no harm." It does include the promise to “keep them from harm and injustice.” Emergency medical technicians, physical therapists, and veterinarians are among those in the healing professions who take an oath.

As a licensed therapist, I took no oath when I received my license to practice.  Professional mental health therapists swear nothing. Doctors have the Hippocratic oath, which, contrary to popular belief, does not start with, or even include the phrase,  “First, do no harm." It does include the promise to “keep them from harm and injustice.” Emergency medical technicians, physical therapists, and veterinarians are among those in the healing professions who take an oath.

How can it be, that we who are dedicated to the healing of trauma, can participate in torture? The American Psychiatric Association and the American Medical Association have declared that participation in interrogations violates basic international human rights and the ethical imperative to do no harm. The American Anthropological Association condemns the use of anthropological knowledge as an element of physical or psychological torture.

The American Psychological Association's (APA) position on torture is clear and unequivocal: Any direct or indirect participation in any act of torture or other forms of cruel, inhuman or degrading treatment or punishment by psychologists is strictly prohibited. There are no exceptions. Such acts as waterboarding, sexual humiliation, stress positions and exploitation of phobias are clear violations of APA's no torture/no abuse policy.

APA's timeline of its response to torture is available here.

Psychologists were allowed to participate in military interrogations until recently. Quoting from the American Psychological Association website:

Based on years of careful and thorough analysis, APA has affirmed that psychology has a vital role to play in promoting the use of ethical interrogations to safeguard the welfare of detainees and facilitate communications with them. By staying engaged, APA is able to work with the many parties, both within and outside of the military, who are dedicated to preventing torture and other forms of cruel, inhumane and degrading treatment. (Source: “Frequently asked questions regarding APA’s policies and positions on the use of torture or cruel, inhuman or degrading treatment during interrogations” (2007, November 15). In APA online Retrieved 21:02, November 15, 2007, from http://www.apa.org/releases/faqinterrogation.html)

In writing this course, we began to wonder why there are so few oaths which define our responsibilities as therapists. We compiled the oaths we found; please click here her to open a new window and see them.

Please click here for Oaths by Professional Associations

Please click here for Universal Declaration of Human Rights

Good Ethics equal Good Therapy. When we, as clinicians, have good boundaries, our patients feel safer to explore the depths of their pain. When we, as clinicians, respect and honor confidentiality, our patients feel safer to explore their problems. When we, as clinicians, report child abuse and elder abuse, our patients feel safer, and society is safer. When we, as clinicians, follow the scope of our practice, our patients feel more confident. When we, as clinicians, practice informed consent, our patients know what to expect. This course is designed to help therapists identify the components and importance of good ethical behavior in clinical practice.

 

AUTHORS' DISCLAIMER
The material contained in this course is not a substitute for legal, ethical or clinical advice or consultation. This is NOT a legal document. This material is solely for the purpose of continuing education; it is not a substitute  for personal or clinical consultation, or legal advice.

Laws, standards , guidelines, and regulations  often change. Students should stay in touch with their professional associations, state licensing boards and other state or federal agencies for the most current legislation, guidelines and information.

All material included in this course is either in the public domain, or used with express permission.

Psychologists have many masters in regard to law and the ethics:

Their own moral compasses
Regulations of the agency or practice for which they work
State Licensing Board
State and APA Ethics Codes
State and Federal laws

The APA Code of Ethics states:

1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority
If psychologists' ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists make known their commitment to the Ethics Code and take steps to resolve the conflict. If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority.

Regarding specific statutes, please check with your licensing board, as the law varies from state to state!

 

Studies in Moral Development and Education Moral Development and Moral Education: An Overview Moral education is becoming an increasingly popular topic in the fields of psychology and education. Media reports of increased violent juvenile crime, teen pregnancy, and suicide have caused many to declare a moral crisis in our nation. While not all of these social concerns are moral in nature, and most have complex origins, there is a growing trend towards linking the solutions to these and related social problems to the teaching of moral and social values in our public schools. However, considerations of the role schools can and should play in the moral development of youth are themselves the subject of controversy. All too often debate on this topic is reduced to posturing reflecting personal views rather than informed opinion. Fortunately, systematic research and scholarship on moral development has been going on for most of this century, and educators wishing to attend to issues of moral development and education may make use of what has been learned through that work. The following overview provides an introduction to the main perspectives guiding current work on moral development and education. Piaget's Theory Jean Piaget is among the first psychologists whose work remains directly relevant to contemporary theories of moral development. In his early writing, he focused specifically on the moral lives of children, studying the way children play games in order to learn more about children's beliefs about right and wrong(1932/65). According to Piaget, all development emerges from action; that is to say, individuals construct and reconstruct their knowledge of the world as a result of interactions with the environment. Based on his observations of children's application of rules when playing, Piaget determined that morality, too, can be considered a developmental process. For example, Ben, a ten year old studied by Piaget, provided the following critique of a rule made-up by a child playing marbles: "it isn't a rule! It's a wrong rule because it's outside of the rules. A fair rule is one that is in the game". Ben believed in the absolute and intrinsic truth of the rules, characteristic of early moral reasoning. In contrast, Vua, aged thirteen, illustrates an understanding of the reasoning behind the application of rules, characteristic of later moral thinking. When asked to consider the fairness of a made-up rule compared to a traditional rule, Vua replied "It is just as fair because the marbles are far apart"(making the game equally difficult). In addition to examining children's understanding of rules about games, Piaget interviewed children regarding acts such as stealing and lying. When asked what a lie is, younger children consistently answered that they are "naughty words". When asked why they should not lie, younger children could rarely explain beyond the forbidden nature of the act: "because it is a naughty word". However, older children were able to explain "because it isn't right", and "it wasn't true". Even older children indicated an awareness of intention as relevant to the meaning of an act: "A lie is when you deceive someone else. To make a mistake is when you make a mistake". From his observations, Piaget concluded that children begin in a "heteronomous" stage of moral reasoning, characterized by a strict adherence to rules and duties, and obedience to authority. This heteronomy results from two factors. The first factor is the young child's cognitive structure. According to Piaget, the thinking of young children is characterized by egocentrism. That is to say that young children are unable to simultaneously take into account their own view of things with the perspective of someone else. This egocentrism leads children to project their own thoughts and wishes onto others. It is also associated with the uni-directional view of rules and power associated with heteronomous moral thought, and various forms of "moral realism." Moral realism is associated with "objective responsibility", which is valuing the letter of the law above the purpose of the law. This is why young children are more concerned about the outcomes of actions rather than the intentions of the person doing the act. Moral realism is also associated with the young child's belief in "immanent justice." This is the expectation that punishments automatically follow acts of wrong-doing. One of the most famous cases of such childhood thinking was that of the young boy who believed that his hitting a power pole with his baseball bat caused a major power blackout in the New York city area. The second major contributor to heteronomous moral thinking in young children, is their relative social relationship with adults. In the natural authority relationship between adults and children, power is handed down from above. The relative powerlessness of young children, coupled with childhood egocentrism feeds into a heteronomous moral orientation. However, through interactions with other children in which the group seeks a to play together in a way all find fair, children find this strict heteronomous adherence to rules sometimes problematic. As children consider these situations, they develop towards an "autonomous" stage of moral reasoning, characterized by the ability to consider rules critically, and selectively apply these rules based on a goal of mutual respect and cooperation. The ability to act from a sense of reciprocity and mutual respect is associated with a shift in the child's cognitive structure from egocentrism to perspective taking. Coordinating one's own perspective with that of others means that what is right needs to be based on solutions that meet the requirements of fair reciprocity. Thus, Piaget viewed moral development as the result of interpersonal interactions through which individuals work out resolutions which all deem fair. Paradoxically, this autonomous view of morality as fairness is more compelling and leads to more consistent behavior than the heteronomous orientation held by younger children. Piaget concluded from this work that schools should emphasize cooperative decision-making and problem solving, nurturing moral development by requiring students to work out common rules based on fairness. This is a direct rejection of sociologists Emile Durkheim's view of proper moral education (1925/1961). Durkheim, similar to Piaget, believed that morality resulted from social interaction or immersion in a group. However, Durkheim believed moral development was a natural result of attachment to the group, an attachment which manifests itself in a respect for the symbols, rules, and authority of that group. Piaget rejected this belief that children simply learn and internalize the norms for a group; he believed individuals define morality individually through their struggles to arrive at fair solutions. Given this view, Piaget suggested that a classroom teacher perform a difficult task: the educator must provide students with opportunities for personal discovery through problem solving, rather than indoctrinating students with norms. An excellent contemporary adaptation of Piaget's theory for moral development of young children may be found in DeVries, R. & Zan, B. (1994). "Moral Children: Constructing a Constructivist Atmosphere in Early Education." New York: Teachers College Press. You may preview some portions of that book within the FEATURED PRACTICES segment of this WEB site. DeVries and Zan go beyond Piaget's original work to include that of more recent theorists including Lawrence Kohlberg whose theory will be described next. Kohlberg's Theory of Moral Development and Education Moral Development Lawrence Kohlberg (1969) modified and elaborated Piaget's work, and laid the groundwork for the current debate within psychology on moral development. Consistent with Piaget, he proposed that children form ways of thinking through their experiences which include understandings of moral concepts such as justice, rights, equality and human welfare. Kohlberg followed the development of moral judgment beyond the ages studied by Piaget, and determined that the process of attaining moral maturity took longer and was more gradual than Piaget had proposed. On the basis of his research, Kohlberg identified six stages of moral reasoning grouped into three major levels. Each level represented a fundamental shift in the social-moral perspective of the individual. At the first level, the preconventional level, a person's moral judgments are characterized by a concrete, individual perspective. Within this level, a Stage 1 heteronomous orientation focuses on avoiding breaking rules that are backed by punishment, obedience for its own sake and avoiding the physical consequences of an action to persons and property. As in Piaget's framework, the reasoning of Stage 1 is characterized by ego-centrism and the inability to consider the perspectives of others. At Stage 2 there is the early emergence of moral reciprocity. The Stage 2 orientation focuses on the instrumental, pragmatic value of an action. Reciprocity is of the form, "you scratch my back and I'll scratch yours." The Golden Rule becomes, "If someone hits you, you hit them back." At Stage 2 one follows the rules only when it is to someone's immediate interests. What is right is what's fair in the sense of an equal exchange, a deal, an agreement. At Stage 2 there is an understanding that everybody has his(her) own interest to pursue and these conflict, so that right is relative (in the concrete individualist sense). Individuals at the conventional level of reasoning, however, have a basic understanding of conventional morality, and reason with an understanding that norms and conventions are necessary to uphold society. They tend to be self-identified with these rules, and uphold them consistently, viewing morality as acting in accordance with what society defines as right. Within this level, individuals at Stage 3 are aware of shared feelings, agreements, and expectations which take primacy over individual interests. Persons at Stage 3 define what is right in terms of what is expected by people close to one's self, and in terms of the stereotypic roles that define being good - e.g., a good brother, mother, teacher. Being good means keeping mutual relationships, such as trust, loyalty, respect, and gratitude. The perspective is that of the local community or family. There is not as yet a consideration of the generalized social system. Stage 4 marks the shift from defining what is right in terms of local norms and role expectations to defining right in terms of the laws and norms established by the larger social system. This is the "member of society" perspective in which one is moral by fulfilling the actual duties defining one's social responsibilities. One must obey the law except in extreme cases in which the law comes into conflict with other prescribed social duties. Obeying the law is seen as necessary in order to maintain the system of laws which protect everyone. Finally, the post conventional level is characterized by reasoning based on principles, using a "prior to society" perspective. These individuals reason based on the principles which underlie rules and norms, but reject a uniform application of a rule or norm. While two stages have been presented within the theory, only one, Stage 5, has received substantial empirical support. Stage 6 remains as a theoretical endpoint which rationally follows from the preceding 5 stages. In essence this last level of moral judgment entails reasoning rooted in the ethical fairness principles from which moral laws would be devised. Laws are evaluated in terms of their coherence with basic principles of fairness rather than upheld simply on the basis of their place within an existing social order. Thus, there is an understanding that elements of morality such as regard for life and human welfare transcend particular cultures and societies and are to be upheld irrespective of other conventions or normative obligations. These stages (1-5) have been empirically supported by findings from longitudinal and cross-cultural research (Power et al., 1989). Moral Education Kohlberg used these findings to reject traditional character education practices. These approaches are premised in the idea that virtues and vices are the basis to moral behavior, or that moral character is comprised of a "bag of virtues", such as honesty, kindness, patience, strength, etc. According to the traditional approach, teachers are to teach these virtues through example and direct communication of convictions, by giving students an opportunity to practice these virtues, and by rewarding their expression. However, critiques of the traditional approach find flaws inherent in this model. This approach provides no guiding principle for defining what virtues are worthy of espousal, and wrongly assumes a community consensus on what are considered "positive values". In fact, teachers often end up arbitrarily imposing certain values depending upon their societal, cultural, and personal beliefs. In order to address this issue of ethical relativity, some have adopted the values-clarification approach to moral education. This teaching practice is based on the assumption that there are no single, correct answers to ethical dilemmas, but that there is value in holding clear views and acting accordingly. In addition, there is a value of toleration of divergent views. It follows, then, that the teacher's role is one of discussion moderator, with the goal of teaching merely that people hold different values; the teacher does attempt to present her views as the "right" views. Kohlberg rejected the focus on values and virtues, not only due to the lack of consensus on what virtues are to be taught, but also because of the complex nature of practicing such virtues. For example, people often make different decisions yet hold the same basic moral values. Kohlberg believed a better approach to affecting moral behavior should focus on stages of moral development. These stages are critical, as they consider the way a person organizes their understanding of virtues, rules, and norms, and integrates these into a moral choice (Power, Higgins, & Kohlberg, 1989). In addition, he rejected the relativist view point in favor of the view that certain principles of justice and fairness represent the pinnacle of moral maturity, as he found that these basic moral principles are found in different cultures and subcultures around the world (Kohlberg & Turiel, 1971). The goal of moral education, it then follows, is to encourage individuals to develop to the next stage of moral reasoning. Initial educational efforts employing Kohlberg's theory were grounded in basic Piagetian assumptions of cognitive development. Development, in this model, is not merely the result of gaining more knowledge, but rather consists of a sequence of qualitative changes in the way an individual thinks. Within any stage of development, thought is organized according to the constraints of that stage. An individual then interacts with the environment according to their basic understandings of the environment. However, the child will at some point encounter information which does not fit into their world view, forcing the child to adjust their view to accommodate this new information. This process is called equilibration, and it is through equilibration that development occurs. Early moral development approaches to education, therefore, sought to force students to ponder contradiction inherent to their present level of moral reasoning. The most common tool for doing this was to present a "moral dilemma" and require students to determine and justify what course the actor in the dilemma should take. Through discussion, students should then be forced to face the contradictions present in any course of action not based on principles of justice or fairness. While Kohlberg appreciated the importance and value of such moral dilemma discussions, he held from very early on that moral education required more than individual reflection, but also needed to include experiences for students to operate as moral agents within a community. In this regard, Kohlberg reconciled some of the differences in orientation that existed between the theories of moral growth held by Piaget and Durkheim. In order to provide students with an optimal context within which to grow morally, Kohlberg and his colleagues developed the "just community" schools approach towards promoting moral development (Power, Higgins, & Kohlberg, 1989). The basic premise of these schools is to enhance students' moral development by offering them the chance to participate in a democratic community. Here, democracy refers to more than simply casting a vote. It entails full participation of community members in arriving at consensual rather than "majority rules" decision-making. One primary feature of these schools is their relatively small size (often they are actually schools within schools), aimed at providing the students with a sense of belonging to a group which is responsive to individual needs. The central institution of these schools is a community meeting in which issues related to life and discipline in the schools are discussed and democratically decided, with an equal value placed on the voices of students and teachers. An underlying goal of these meetings is to establish collective norms which express fairness for all members of the community. It is believed that by placing the responsibility of determining and enforcing rules on students, they will take prosocial behavior more seriously. At the same time, this approach stems from the cognitive-developmentalist view that discussion of moral dilemmas can stimulate moral development. However, this is not to say that just community school simply leaves students to their own devices; teachers play a crucial leadership role in these discussions, promoting rules and norms which have a concern for justice and community, and ultimately enforcing the rules. This role is not an easy one, as teachers must listen closely and understand a student's reasoning, in order to help the student to the next level of reasoning. This requires a delicate balance between letting the students make decisions, and advocating in a way which shows them the limits in their reasoning. A primary advantage to the Just Community approach is its effectiveness in affecting students actions, not just their reasoning. Students are, in effect, expected to "practice what they preach", by following the rules determined in community meetings. The most comprehensive and authoritative source for work on Kohlberg's approach to moral education is to be found in : Power, F. C., Higgins, A., & Kohlberg, L. (1989). "Lawrence Kohlberg's Approach to Moral Education." New York: Columbia University Press. Domain Theory: Distinguishing Morality and Convention In the early 1970s, longitudinal studies conducted by the Kohlberg research group began to reveal anomalies in the stage sequence. Researchers committed to the basic Kohlberg framework attempted to resolve those anomalies through adjustments in the stage descriptions (see the Power, Higgins, & Kohlberg, 1989 reference for an account of those changes). Other theorists, however, found that a comprehensive resolution to the anomalous data required substantial adjustments in the theory itself. One of the most productive lines of research to come out of that period has been the domain theory advanced by Elliot Turiel and his colleagues. Within domain theory a distinction is drawn between the child's developing concepts of morality, and other domains of social knowledge, such as social convention. According to domain theory, the child's concepts of morality and social convention emerge out of the child's attempts to account for qualitatively differing forms of social experience associated with these two classes of social events. Actions within the moral domain, such as unprovoked hitting of someone, have intrinsic effects (i.e., the harm that is caused) on the welfare of another person. Such intrinsic effects occur irregardless of the nature of social rules that may or may not be in place regarding the action. Because of this, the core features of moral cognition are centered around considerations of the effects which actions have upon the well-being of persons. Morality is structured by concepts of harm, welfare, and fairness. In contrast, actions that are matters of social convention have no intrinsic interpersonal consequences. For example, there is nothing intrinsic to the forms of address we employ that makes calling a college teacher "professor" better or worse than calling the person Mr. or Ms., or simply using their given names. What makes one form of address better than another is the existence of socially agreed upon rules. These conventions, while arbitrary in the sense that they have no intrinsic status, are nonetheless important to the smooth functioning of any social group. Conventions provide a way for members of the group to coordinate their social exchanges through a set of agreed upon and predictable modes of conduct. Concepts of convention then, are structured by the child's understandings of social organization. These hypothesized distinctions have been sustained through studies over the past 20 years. These studies have included interviews with children, adolescents and adults; observations of child-child and adult-child social interactions; cross-cultural studies; and longitudinal studies examining the changes in children's thinking as they grow older. An example of the distinction between morality and convention is given in the following excerpt from an interview with a four-year-old girl regarding her perceptions of spontaneously occurring transgressions at her preschool. MORAL ISSUE: Did you see what happened? Yes. They were playing and John hit him too hard. Is that something you are supposed to do or not supposed to do? Not so hard to hurt. Is there a rule about that? Yes. What is the rule? You're not to hit hard. What if there were no rule about hitting hard, would it be all right to do then? No. Why not? Because he could get hurt and start to cry. CONVENTIONAL ISSUE: Did you see what just happened? Yes. They were noisy. Is that something you are supposed to or not supposed to do? Not do. Is there a rule about that? Yes. We have to be quiet. What if there were no rule, would it be all right to do then? Yes. Why? Because there is no rule. Morality and convention, then, are distinct, parallel developmental frameworks, rather than a single system as thought of by Kohlberg. However, because all social events, including moral ones, take place within the context of the larger society, a person's reasoning about the right course of action in any given social situation may require the person to access and coordinate their understandings from more than one of these two social cognitive frameworks. For, example, whether people line up to buy movie theater tickets is largely a matter of social convention. Anyone who has traveled outside of Northern Europe or North America can attest to the fact that lining up is not a shared social norm across cultures. Within the United States or England, for example, lining up is the conventional way in which turn-taking is established. The act of turn-taking has a moral consequence. It establishes a mechanism for sharing - an aspect of distributive justice. The act of breaking in line within the American or British context is more than merely a violation of convention. It is a violation of a basic set of rules that people hold to maintain fairness. How people coordinate the possible interactions that may arise between issues of morality and convention is a function of several factors including: the salience of the features of the act (what seems most important - the moral or conventional elements); and the developmental level of the person (adolescents for example view conventions as unimportant and arbitrary norms established by adult authority). It was Turiel's insight to recognize that what Kohlberg's theory attempts to account for within a single developmental framework is in fact the set of age-related efforts people make at different points in development to coordinate their social normative understandings from several different domains. Thus, domain theory posits a great deal more inconsistency in the judgments of individuals across contexts, and allows for a great deal more likelihood of morally (fairness and welfare) based decisions from younger and less developed people than would be expected from within the traditional Kohlberg paradigm. Current work from within domain theory has sought to explore how the child's concepts of moral and conventional regulation relate to their developing understandings of personal prerogative and privacy. This work is exploring how children develop their concepts of autonomy and its relation to social authority. This has led to a fruitful series of studies of adolescent-parent conflict with important implications for ways in which parents may contribute to the healthy development of youth (Smetana, 1996). This work is also being extended into studies of how adolescents perceive the authority of teachers and school rules. Moral and Social Values Education The implications of domain theory for values education are several. First, the identification of a domain of moral cognition that is tied to the inherent features of human social interaction means that moral education may be grounded in universal concerns for fairness and human welfare, and is not limited to the particular conventions or norms of a given community or school district. By focusing on those universal features of human moral understanding, public schools may engage in fostering children's morality without being accused of promoting a particular religion, and without undercutting the basic moral core of all major religious systems. Second, educational research from within domain theory has resulted in a set of recommendations for what is termed "domain appropriate" values education. This approach entails the teacher's analysis and identification of the moral or conventional nature of social values issues to be employed in values lessons. Such an analysis contributes to the likelihood that the issues discussed are concordant with the domain of the values dimension they are intended to affect. A discussion of dress codes, for example, would constitute a poor basis for moral discussion, since mode of dress is primarily a matter of convention. Likewise, consideration of whether it is right to steal to help a person in need, would be a poor issue with which to generate a lesson intended to foster students' understandings of social conventions. A related function of the teacher would be to focus student activity (verbal or written) on the underlying features concordant with the domain of the issue. Thus, students dealing with a moral issue would be directed to focus on the underlying justice or human welfare considerations of the episode. With respect to conventions, the focus of student activity would be on the role of social expectations and the social organizational functions of such social norms. On the basis of this kind of analysis teachers are also better enabled to lead students through consideration of more complex issues which contain elements from more than one domain. By being aware of the developmental changes that occur in students' comprehension of the role of social convention, and related changes in students understanding of what it means to be fair or considerate of the welfare of others, teachers are able to frame consideration of complex social issues in ways that will maximize the ability of students to comprehend and act upon the moral and social meaning of particular courses of action. The best sources for discussion of domain appropriate education, along with guidelines and examples for how teachers may select materials from existing school curricula from which to generate lessons and practices which will foster students' development within both the moral and conventional domains may be found in: Nucci, L. & Weber, E. (1991) "The domain approach to values education: From theory to practice" In W. Kurtines & J. Gewirtz (Eds.) "Handbook of Moral Behavior and Development (Volume 3: Applications)pp. 251 - 266). and also in: Nucci, L. (1989) "Challenging Conventional Wisdom About Morality: The Domain Approach to Values Education." In L. Nucci (Ed.) "Moral Development and Character Education: A Dialogue" Berkeley: McCutchan.   Carol Gilligan and the Morality of Care A second major critique of Kohlberg's work was put forth by Carol Gilligan, in her popular book, "In a Different Voice: Psychological Theory and Women's Development" (1982). She suggested that Kohlberg's theories were biased against women, as only males were used in his studies. By listening to women's experiences, Gilligan offered that a morality of care can serve in the place of the morality of justice and rights espoused by Kohlberg. In her view, the morality of caring and responsibility is premised in nonviolence, while the morality of justice and rights is based on equality. Another way to look at these differences is to view these two moralities as providing two distinct injunctions - the injunction not to treat others unfairly (justice) and the injunction not to turn away from someone in need (care). She presents these moralities as distinct, although potentially connected. In her initial work, Gilligan emphasized the gender differences thought to be associated with these two orientations. The morality of care emphasizes interconnectedness and presumably emerges to a greater degree in girls owing to their early connection in identity formation with their mothers. The morality of justice, on the other hand, is said to emerge within the context of coordinating the interactions of autonomous individuals. A moral orientation based on justice was proposed as more prevalent among boys because their attachment relations with the mother, and subsequent masculine identity formation entailed that boys separate from that relationship and individuate from the mother. For boys, this separation also heightens their awareness of the difference in power relations between themselves and the adult, and hence engenders an intense set of concerns over inequalities. Girls, however, because of their continued attachment to their mothers, are not as keenly aware of such inequalities, and are, hence, less concerned with fairness as an issue. Further research has suggested, however, that moral reasoning does not follow the distinct gender lines which Gilligan originally reported. The preponderance of evidence is that both males and females reason based on justice and care. While this gender debate is unsettled, Gilligan's work has contributed to an increased awareness that care is an integral component of moral reasoning. Educational approaches based on Gilligan's work have emphasized efforts to foster empathy and care responses in students. Perhaps the most comprehensive treatment of these issues may be found in Nel Noddings book, "The challenge to care in schools" New York: Teachers College Press, 1992. This overview was prepared by Mary Elizabeth Murray, Department of Psychology, University if Illinois at Chicago. Selected References Gilligan, C. (1982). In a different voice: Psychological theory and women's development. Harvard University Press: Cambridge. Kohlberg, L. & Turiel, E. (1971). Moral development and moral education. In G. Lesser, ed. Psychology and educational practice. Scott Foresman. Piaget, J. (1965). The moral judgment of the child. The Free Press: New York. Power, F. C., Higgins, A., & Kohlberg, L. (1989). "Lawrence Kohlberg's Approach to Moral Education." New York: Columbia University Press. Smetana, J. G. (1996, in press). "Parenting and the development of social knowledge reconceptualized: A social domain analysis." To appear in J.E. Grusec & L. Kuczynski (Eds.), Handbook of parenting and the transmission of values. New York: Wiley. Turiel, E. (1983). "The Development of Social Knowledge: Morality & Convention." New York: Cambridge University Press. Reprinted by permission of the author

1. I will, first, do no harm...

I will strive to be wise, and contained with those in my care.

 

"Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm."

this has been attributed to Hippocrates, and to Galen, but, contrary to popular belief, is not part of the Hippocratic Oath.

Respect and honor Client Welfare

If you are following the course plotted by the rules and regulations for informed consent, accountability, competence, scope of practice and confidentiality your clients should be guided within safe parameters. 

Clear boundaries
Dual Relationships

There are many ways in which therapists err with regard to boundaries. One way to guard against this is to imagine that the therapeutic container is "sacred space", a temenos or 'free and protected' place. Conceptualize psychotherapy as a safe place in which competent help is given in a clear and respectful manner, a place where the psyche of the client is honored above all. Anything that interferes with this is unethical and possibly illegal. That includes most contact outside of the therapeutic hour, including having coffee or lunch with a client, hiring a client, bartering with a patient for therapy in exchange for services or products, working with a client in more than one capacity, and most certainly, having a sexual relationship with a client. The simplest and safest guideline is to keep the relationship within the therapeutic hour. We are aware however there are many questions in this area. It is the therapist's responsibility to check with their internal 'moral compass' as well as their attorney to guide them through these murky waters. The relevant citation from CAMFT's Ethical Standards for Marriage and Family Therapists, Section 1.2 reads as follows:

 
Marriage and family therapists are cognizant of their potentially influential position with respect to patients, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists avoid dual relationships with patients that could impair their professional judgment or increase the risk of exploitation. Sexual intercourse, sexual contact or sexual intimacy with patients or a patient's spouse or partner is unethical.

A sexual relationship between a therapist and a client is never appropriate.  It is unethical, illegal, and destructive to the client. It is more about power than sex because the therapeutic relationship is an unequal one. We are being hired to help a client through their times of trouble.  Although there maybe strong sexual transference , there is no reason to lose the professional boundary and expect that a sexually intimate relationship with a client would be therapeutic.

Give patients, when appropriate, the pamphlet "Professional Therapy Never Includes Sex"

In California there is a pamphlet that we are required to give to our clients who have had a sexual relationship with a therapist. It is a Department of Consumer Affairs publication entitled "Professional Therapy Never Includes Sex".  It is available on-line at: www.psychceu.com/proftherapy.pdf.

Honor the Patient Bill of Rights
Definitions and warning Signs
Where to Start
What Can You Do?
Reporting Options
Administrative Action
How the Complaint Process Works
Professional Association Action
Civil Action
Finding an Attorney
Criminal Action
Where to Get Help Finding a Therapist
Self-Help Support Groups
Frequently Asked Questions

There have been therapists who have been disciplined by their licensing boards for not supplying this pamphlet to clients who say they have had a sexual relationship with a previous therapist. Single copies of the publication are available at no charge from Publications Office, California Department of Consumer Affairs, PO Box 310, Sacramento California 95802.  For a copy of the Board of Behavioral Science Examiners Licensing Laws and Regulations, go to: http://www.psychceu.com/ethics/lawsregs.pdf.

 

Hippocratic oath:

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

Did you know? Acts which are subject to disciplinary action (revocation, suspension, or probationary status of a license) include, but are not limited to, unprofessional conduct, sexual misconduct, gross negligence, conviction of a substantially related crime, substance abuse or use of drugs with a client, intentionally or recklessly causing harm to a client, practicing beyond the scope of the license, failure to maintain confidentiality, failure to adhere to reporting requirements, failure to obtain client consent for services, etc.

 

 

. 2. I will speak up against torture, exploitation and violence, and tolerate no bullying.

Is it ethical to participate in
Torture?
Guantanamo, Abu Ghraib & Afghanistan

The field today is being rocked by psychology professionals participating in the torture of prisoners:

"The American Medical Association last month adopted what many view as a stronger stand against physician involvement in prisoner interrogation, echoing a position held by the American Psychiatric Association, whose members are medical doctors. The U.S. military has indicated it will therefore favor using psychologists, who are not medical doctors and are not bound by the other groups' policies."

Psychologist Mary Pipher decided to return her Presidential Citation award from the American Psychological Association in protest. Here is her letter:

August 21, 2007

American Psychological Association,
750 First Street, NE,
Washington, DC 20002-4242

President Brehm:

I am writing to inform you that I am returning my Presidential Citation dated 2/02/06 and awarded to me by then President of the American Psychological Association, Dr. Gerald Koocher. I have struggled for many months with this decision, and I make it with pain and sorrow. I was honored to receive this award and proud to be a member of APA. Over the years I have spoken at national conventions many times and had enjoyed an excellent relationship with the APA and its staff. With this letter, I feel as if I am ostracizing a good friend.

I do not want an award from an organization that sanctions its members' participation in the enhanced interrogations at CIA Black Sites and at Guantanamo. The presence of psychologists has both educated the interrogation teams in more skillful methods of breaking people down and legitimized the process of torture in defiance of the Geneva Conventions.

The behavior of psychologists on these enhanced interrogation teams violates our own Code of Ethics (2002) in which we pledge to respect the dignity and worth of all people, with special responsibility towards the most vulnerable. I consider prisoners in secret CIA-run facilities with no right of habeas corpus or access to attorneys, family or media to be highly vulnerable. I also believe that when any of us are degraded, all of human life is degraded. This letter is as much about us as it is about prisoners.

In our Ethics Code we agree to promote honesty and accuracy. Our involvement in these projects has been secretive and dishonest. Finally, as psychologists we vow to do no harm. Without question, we violate this oath when we allow people in our care to be deprived of sleep or subjected to sensory over-stimulation or deprivation.

I cannot accept the August 19, 2007 Reaffirmation of APA's Position Against Torture (Substitute Motion Three). Under this motion, psychologists will be allowed to continue working on interrogation teams that are not subject to the Geneva Conventions. This motion places our organization on the side of the CIA and Department of Defense and at odds with the United Nations, The Red Cross, the American Psychiatric Association and the American Medical Association. With this reaffirmation we have made a terrible mistake.

I know that the return of my Presidential Citation from Dr. Koocher will be of small import, but it is what I can do to disassociate myself from what I consider to be a heinous policy. All of my life I have tried my best to stand up for those with no voices and no power. The prisoners our government labels as enemy combatants are in this category.

I return my citation as a matter of conscience and in the hopes that the APA will reconsider its current unethical position. We have long been a wonderful organization that respected human rights and promoted tolerance, kindness, and peace. Nothing is more fundamental to our core orientation and professional service to others than our commitment to all people's inherent dignity, safety and welfare. I hope my letter may be useful in restoring the APA to its long-respected and important stance as a beacon of integrity and kindness for all human beings.

Respectfully,

Dr. Mary Pipher

(source: http://www.zmag.org/content/showarticle.cfm?ItemID=13625)

Read the Vanity Fair article

Please view the American Psychologist Association Code of Ethics

In particular, please review GENERAL PRINCIPLES in regard to The Therapist's Oath

Principle A: Beneficence and Nonmaleficence
Principle B: Fidelity and Responsibility
Principle C: Integrity
Principle D: Justice
Principle E: Respect for People's Rights and Dignity

The Canadian Code of Ethics for Psychologists includes the following:

IV.27 Not contribute to nor engage in research or any other activity that contravenes international humanitarian law, such as the development of methods intended for use in the torture of persons,the development of prohibited weapons, or destruction of the environment.

Please visit Psychologists for Social Responsibility

RETHINKING THE PSYCHOLOGY OF TORTURE Contact: Colleen Cordes, executive director, Psychologists for Social Responsibility, www.psysr.org 202-543-5347, or ccordes@psysr.org or Andrew Pino, Georgetown Media Relations, 202-687-4328, pinoa@georgetown.edu For immediate release—November, 2006 RETHINKING THE PSYCHOLOGY OF TORTURE: A Preliminary Report from Former Interrogators and Research Psychologists Torture does not yield reliable information and is actually counterproductive in intelligence interrogations, which aim to produce the maximum amount of accurate information in the minimum amount of time. In fact, popular assumptions that torture works conflict with the most effective methodologies of interrogation, as well as with fundamental tenets of psychology. That was the conclusion of a research seminar in November composed of retired senior military interrogators and research psychologists from diverse fields. The group met at Georgetown University and formed a study group to consider the psychology of torture. The interrogators, all of whom are also peripherally involved in training interrogators, have conducted interrogation and other human intelligence operations in Vietnam, Grenada, Desert Storm, Bosnia, Kosovo, and the ongoing war in Iraq. They reviewed for the psychologists the U.S. military training program for interrogators and the established interrogation methodologies, which exclude torture. The psychologists were able to understand the effectiveness of the diverse, established interrogation methods in terms of psychological theories and research. The group then moved to an analysis of the ineffectiveness of torture as an interrogation tool. The interrogators maintained that, even in the most urgent situations, torture can not be considered a viable option. The involuntary circumstances of the disclosure would compromise the integrity of the information obtained. Decades of research into directly relevant topics such as social influence, stress, cultural and religious identification, false confessions, and interpersonal relationships point to the same conclusion, according to the psychologists. Naïve assumptions that torture “works” fail to recognize that, under torture, the innocent are apt to fabricate and those with real information and training to resist interrogation are apt to alter the information or present carefully rehearsed lies instead. A common argument for torture is the “ticking time bomb” scenario, in which a terrorist who knows the location of a bomb is tortured in a race to save lives. Interrogators stated that the terrorist would know that he only has to keep his secret for the short time until the bomb detonates—a time period known to him but not to the interrogators. Moreover, the torture would offer the terrorist a prime opportunity to deceive interrogators by falsely naming bomb locations of difficult access. In their combined 100 years of interrogation experience, the interrogators had never encountered a true ticking bomb scenario. According to the interrogators, harsh approaches are typically the first choice of novice and untrained interrogators but the last choice of experienced professional interrogators. The detainee’s fear, the interrogators said, can easily turn to anger, which may escalate to the point that the interrogator cannot re-establish emotional control of the situation. The interrogator then loses all possibility of cooperation from the detainee. But cooperation is crucial to the goal of trustworthy information. Severe stress and injury, interrogators added, may also impair the mental ability of the detainee to provide accurate information. One psychologist speculated on reasons for the centuries-old “folk belief” in the effectiveness of torture interrogation. For example, schoolyard bullies, abusive parents, and muggers attempt to make their targets comply physically through threat and force. In contrast, the interrogator seeks willing mental compliance. Another psychologist noted that confidence in torture interrogation follows from the outdated behaviorist conception of human behavior, which dominated psychology in the first half of the 20th century. The idea was that the behavior of humans, much like the behavior of rats, is controlled primarily by external rewards and punishments. Today, psychologists in brain science, cognitive psychology, and social psychology have come to appreciate the inherent complexity of human thought, emotion, and action. It has been shown that people not only operate independently of rewards and punishments but often in direct opposition to them. The study group was sponsored by Psychologists for Social Responsibility and the Georgetown University Department of Psychology, and its work was made possible through a generous grant from the David and Carol Myers Foundation. The joint group of psychologists and interrogators plans to continue its examination of the relative effectiveness of coercive and non-coercive interrogation methodologies. Its findings will be shared with the public, policymakers, and international professional associations in the field of psychology. Attached is a list of the participating psychologists.

 

3. I will protect those who are vulnerable, and cannot speak up for themselves.

We can break confidentiality only in very specific instances:

when a child is being abused

when an elder person is being abused

when someone "is a danger to others, or to himself or herself, or gravely disabled" (5150 and Tarasoff).

 

Report Child Abuse

Keeping a child safe is good therapy!

For more information, please visit the
 

http://www.childwelfare.gov/

ERIC Identifier: ED315706 Publication Date: 1990-00-00 Author: McFadden, Emily Jean Source: ERIC Clearinghouse on Counseling and Personnel Services Ann Arbor MI. Counseling Abused Children. Highlights: An ERIC/CAPS Digest. Counseling abused children is a challenging task for practitioners. The incidence of reported and substantiated child abuse and neglect has risen dramatically since the "discovery" of the Battered Child Syndrome in the sixties, and subsequent mandatory reporting laws. The nation has moved through stages of public awareness about the phenomenon. Currently practitioners have become aware of the widespread sexual abuse of girls (estimated at one in four females) and are developing increasing awareness of the sexual abuse of boys. Rapid changes in the knowledge base demand that counselors keep abreast of the indicators of maltreatment, the laws for reporting suspected abuse, and the ways in which children can best be served to overcome effects of a negative family experience. All fifty states require that helping professionals report suspected child abuse to the child protection agency or the police. Many counselors experience difficulty with reporting requirements for fear of violating the trust of a child, or creating mistrust with the child's parents. Such reporting to Children's Protective Services has saved the lives of many children, and brought help to families. Although children are still removed from their families and placed in foster homes when it is necessary for their protection, the emphasis has shifted to serving children in their own homes, and providing services to help the family overcome the situations which lead to abuse or neglect. Counselors should be familiar with child abuse reporting laws in their own states. Typically counselors and school personnel are required to report suspected abuse, and are granted immunity from liability because they are presumed to be acting in good faith. Many states also have criminal or civil penalties established for mandated professionals who fail to report. TYPES OF MALTREATMENT A common theme underlying most forms of maltreatment--physical abuse, neglect, or sexual abuse and exploitation--is that of emotional hurt. The child who is physically abused often suffers emotionally from inconsistent parenting and fear. The sexually abused child suffers from the lack of affection or supervision which leaves him/her vulnerable to the subtle advances of the perpetrator; and the neglected child becomes anxious or apathetic about a life in which basic needs aren't met. One general consequence of child maltreatment is developmental fixation or "freezing." The child who comes to the attention of the counselor due to difficulties in the classroom or poor social adjustment may very well be a maltreated child. NEGLECT Neglect accounts for more deaths than the physical abuse of children. In a national study of reported child maltreatment, only 4% experienced major physical injury, while 60% experienced a type of physical neglect. Neglect was associated with 56% of child deaths (American Humane Association, 1983). All types of neglect are essentially a failure by the parents to provide something needed for the child's healthy growth and development. The concept of neglect includes the assumption that some harm must befall the child as a result of the parents' failure to provide. PHYSICAL ABUSE Physical abuse is usually defined as the intentional or nonaccidental inflicting of injury on a child by a caregiver. It manifests as bruises, welts, broken bones, burns, lacerations, or even death. It may occur through hitting, striking, beating, kicking, biting, slapping or other forms of violence directed at a child. Many, if not most, parents who abuse children have been reared in an environment in which some form of maltreatment occurred. Physical abuse appears in all socioeconomic classes, but is correlated with the stresses of poverty. SEXUAL ABUSE AND EXPLOITATION Child sexual abuse is the adult (or older child) exploitation of the normal childhood development process, through the use of sexual activity. Examples of the types of sexual activity might include touching, kissing, fondling, manipulations of the genitals with the fingers, and actual sexual intercourse (Stovall, 1981). In examining patterns of sexual abuse and exploitation, it is important to keep in mind that the knowledge base is changing rapidly. While earlier belief was that sexual abuse perpetrators were almost always men, McCarty (1986) studied female perpetrators and found both accomplices who aided male perpetrators, and independent abusers, who had come from a background of bad childhoods, unhappy marriages and earlier sexual victimization. Within the last decade it has been acknowledged that male children are also sexually victimized and are at great risk (Bolton, Morris, & MacEachron, 1989). It currently appears that female children are more likely to be sexually abused in an incestuous situation, while more male children are sexually abused outside the home. EMOTIONAL ABUSE OR NEGLECT Emotional neglect generally implies a consistent indifference to the child's needs and covers a range of behavior, from the parent who never speaks to the child and doesn't remove the child from a crib, to the psychotic parent unable to acknowledge the reality of the child's world, or that the child actually exists. Emotional abuse, on the other hand, implies an active rejection or persecution of the child by the parent. Chronic verbal abuse erodes the child's self-esteem. The use of confinement or excessive punishment is also a form of emotional abuse. Emotional abuse or neglect is usually accompanied by other forms of maltreatment such as sexual abuse or physical abuse. Clearly, children who are being maltreated are not getting their developmental needs met. IDENTIFYING MALTREATMENT Children who have been maltreated are usually unwilling or unable to reveal their situation to a counselor because of parental threats, or a feeling of loyalty to the family. While sensitive interviewing may help to unearth details of maltreatment, counselors need to be aware of non-verbal ways in which the message of abuse may be communicated. The presence of one indicator alone does not necessarily mean that maltreatment has occurred. The counselor looks rather for configurations of indicators. If there are a number of indicators, the counselor has reason to suspect maltreatment, even if the child has not confided in the counselor. When abuse is suspected, the counselor is obligated, under law, to report this concern to Children's Protective Services. THE TEAM APPROACH Counseling, in and of itself, cannot ensure the safety of a maltreated child. There will be many professionals involved in working with maltreated children. Typically, a Children's Protective Services worker may coordinate the intervention. Medical personnel will be involved. This may include a coordinating pediatrician who will follow the child's growth and development, several specialists and other health practitioners such as a physical therapist or public health nurse who has worked with the family. If the child must be removed from the home, the team may include a foster parent. Educators and school personnel are also an important part of the team. They can help to monitor a child's day-to-day safety and progress, and can build programs to help the child's self-esteem and enhance cognitive development. In dealing with situations where there is risk to a child, the counselor will find that a team approach accomplishes more for the child than the single intervention of offering counseling. COUNSELING THE CHILD One of the primary purposes of counseling the maltreated child is to provide a safe place and safe relationship within which the child may experiment with new adaptations to a safer world, and in which the child's arrested development may become "unstuck." Counselors cannot literally replace the requisite parental bonding which helps children to grow and develop, but have an opportunity to help the child develop a trusting relationship with an adult. The key to understanding the maltreated child is to look at the developmental stage rather than the chronological age. The counselor will be able to identify adaptations which the child made to the maltreatment and teach the child more appropriate ways of interacting. Children often reveal in play the traumatic events of their earlier years. They may also show to the counselor maladaptive behavior which puts them at risk of further maltreatment. In the counseling relationship, working with maltreated children requires many techniques other than talking and listening. Using structured or unstructured play situations and artwork, music or clay provide a safe way for children to release tension and express themselves. Younger children do well with dolls and dollhouses to act out family issues for the counselor. Many maltreated children have not had normal play opportunities and benefit greatly from free play in the counselor's office. Using puppets, reading stories, or acting out role plays are ways in which abused children can try out new approaches to relationships. Abused children also do well when counselors work with them in groups. Younger children do well with developmental play groups, while older children and youth can benefit from activity groups as well as treatment-oriented groups. Group counseling can be especially useful with children and youth who have been sexually abused by reducing their feelings of shame and differentness and helping them to learn how to protect themselves (McFadden, 1989). THE COUNSELOR'S SELF-AWARENESS Counseling abused children is challenging in that it can arouse many complex feelings within the counselor. Anger with the child's parents, uneasiness over the child's acting out, or feelings of frustration and sadness are not uncommon for counselors to face. Anxiety about protecting the children from further maltreatment may be a predominant theme for the counselor. It is important for counselors working with the sensitive issues of maltreatment to seek consultation, supervision, or even treatment for themselves when they become overwhelmed with feelings. Recognizing one's professional limitations can also be helpful. It is important to remember that counseling alone cannot protect children, and that any effective long-term intervention will require a concerted team approach and a community which cares enough to offer adequate resources for families. Children will be healed and protected as families are helped. REFERENCES American Humane Association. (1983). Annual report, 1981: Highlights of official child neglect and abuse reporting. Denver: Author. Bolton, F., Morris, L., & MacEachron, A. (1989). Males at risk: The other side of child sexual abuse. Newbury Park, CA: Sage Publications. McCarty, L. (1986). Mother child incest: Characteristics of the offender. Child Welfare, LXV(5), 447-458. McFadden, E. J. (1989). Counseling abused children. Ann Arbor, MI: ERIC Counseling and Personnel Services Clearinghouse, The University of Michigan. Stovall, B. (1981). Child sexual abuse. Ypsilanti, MI: Eastern Michigan University.

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Mandatory Reporting

Child Abuse of Persons who are now Adults

The current thinking as reflected by the published opinion below is that we are only required to report the incident if the client is under 18 years of age.  If you have any questions or doubts regarding your cases please seek appropriate legal advice.

Therefore, it appears that the express language of the statute is unclear and does not fully serve the intent of the statute. This ambiguity has caused a great deal of confusion and is more appropriately resolved by the Legislature. Until it does, we believe the literal wording of the statute should prevail...there is no mandatory duty to report unless the victim, in the terms of section 11166 (a), is still a child. (This opinion was published in an article by Richard Leslie, in the January/February 1990 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California.)
 

Report Elder Abuse
Keeping an adult safe is good therapy!

California Laws Chapter 769, Statutes of 1986, Chapter 637, Statutes of 1987, and Chapter 1396, Statutes of 1987 provides for
mandatory reporting of physical abuse when: the victim reports that abuse has occurred or if you observe the incident when an injury or condition reasonably leads one to suspect that abuse has occurred. The law requires mandated reporters to make a verbal report immediately, or as soon as possible, followed by a written report within two (2) working days.

For a listing of phone numbers to report for each state, go here.

Department of Health and Human Services Administration on Aging Elder Rights & Resources Elder Abuse Elder Abuse Is a Serious Problem Each year hundreds of thousands of older persons are abused, neglected, and exploited by family members and others. Many victims are people who are older, frail, and vulnerable and cannot help themselves and depend on others to meet their most basic needs. Legislatures in all 50 states have passed some form of elder abuse prevention laws. Laws and definitions of terms vary considerably from one state to another, but all states have set up reporting systems. Generally, adult protective services (APS) agencies receive and investigate reports of suspected elder abuse. The 2004 Survey of State Adult Protective Services, funded by AoA, found the following: A 19.7 percent increase from 2000 – 2004 in the combined total of reports of elder and vulnerable adult abuse and neglect; A 15.6 percent increase from 2000 – 2004 in substantiated cases; In 20 of the states, more than two in five victims (42.8%) were age 80 or older; Most alleged perpetrators in 2003 were adult children (32.6%) or other family members (21.5%), and spouses/intimate partners accounted for 11.3% of the total (11 states responding). Generally Accepted Definitions Elder abuse is an umbrella term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult. Physical abuse is inflicting, or threatening to inflict, physical pain or injury on a vulnerable elder, or depriving them of a basic need. Sexual abuse is the infliction of non-consensual sexual contact of any kind. Emotional or psychological abuse is the infliction of mental or emotional anguish or distress on an elder person through verbal or nonverbal acts. Financial or material exploitation is the illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder. Neglect is the refusal or failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder. Self-neglect is characterized as the behavior of an elderly person that threatens his/her own health or safety. Abandonment - The desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person. Reporting Elder Abuse To report elder abuse, contact APS through your state’s hotline. The APS agency screens calls for potential seriousness, and it keeps the information it receives confidential. If the agency decides the situation possibly violates state elder abuse laws, it assigns a caseworker to conduct an investigation (in cases of an emergency, usually within 24 hours). If the victim needs crisis intervention, services are available. If elder abuse is not substantiated, most APS agencies will work as necessary with other community agencies to obtain any social and health services that the older person needs. The older person has the right to refuse services offered by APS. The APS agency provides service only if the senior agrees or has been declared incapacitated by the court and a guardian has been appointed. The APS agency only takes such action as a last resort. State Elder Abuse Hotlines

 

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Report "clear and immediate probability of physical harm" to others

Tarasoff
Tarasoff situations arise when there has been a legitimate threat made to the well being or property of another in the therapy session. This requires you to make a differential diagnosis of sorts. If a mother comes in and says, "I could just kill that kid...he wrecked the car, and he is flunking out," chances are she is just venting.

What exactly does the Tarasoff legal ruling mandate?  In a 1976 case Tarasoff v. Regents of the University of California, it was held that:

"the right to privacy ends where the public peril begins" and that "clear and immediate probability of physical harm"to others allows for the breaking of confidentiality. 

There are six pieces that must be documented when a patient makes a serious threat of violence before a Tarasoff warning is indicated. They are:
1. a patient
2. tells
3. you, the therapist (or your psychological assistant)
4. a serious threat
5. of physical violence
6. against a reasonably identifiable victim

The consequences of not following the 'duty to warn' include liability, as you may be held responsible for any harm done, not only to the intended victim, but any others who are injured when the patient tries to harm the intended victim.
Document everything if you are going to invoke Tarasoff. This includes the stated threat, the means to carry it out, your attempts to locate the intended victim, as well as notifying the appropriate law enforcement.
(Pelchat, Z., "Tarasoff for Clinicians: A User's Guide to the Law", November/December 2001, The California Therapist)


For more on this, go to "The Privacy Rule", from APA.

THE FLORIDA TARASOFF STATUTE There are nine aspects of Florida law on the issue of Tarasoff that are worth mentioning here (Behnke et al, 2000). Each mental health discipline (license) has its own statute that dictates action in a Tarasoff situation. Indeed, Section 490.0147 applies to psychologists, as does the general statute Section 455.672 that applies to all mental health professionals as discussed below. Common law refers to long-standing (in some cases, centuries old) case law without statute that dictates the outcome of various cases. Unusually, Florida common law and the legislature (statutory duty) go hand-in-hand. Florida psychologists are “required to read the statute itself and to be aware of what Florida courts have said about a mental health professional’s duty when a patient threatens a third party” (Behnke et al, 2000, p. 20). See the following discussion of Section 455.671 and four district court cases that have made relevant Tarasoff rulings. Section 455.671 recognizes communications between a patient and a psychiatrist as normally confidential. It also discusses specific conditions under which a mental health professional may breach confidentiality. Even though the language of Section 455.671 originally applied to psychiatrists only, Florida courts “have read this language expansively by holding that it applies to any practicing mental health professional” (Behnke, 2000, p. 20). Section 455.671 sets forth the requirements of the threat that would permit disclosure of the information: an actual threat may not be in actual words to inflict physical harm an identifiable victim. If a patient makes an actual threat to inflict physical harm on an identifiable victim, the mental health professional (MHP) must make a clinical judgment. The clinician must assess whether the patient is capable of carrying out the threat, assess the likelihood the patient will carry it out, and will it occur in the near future: the patient has the apparent capability to carry out the threat, it is more likely than not the patient will carry out the threat, and the threat will be carried out in the near future. If all the conditions set forth in Section 455.671 are met, the MHP has the discretion to disclose confidential information. Note that the statute’s language is PERMISSIVE – unlike those in many other states, such as California, mental health professionals in Florida are not required to disclose information in the face of a patient’s threat to harm a third party. Florida’s law does not impose a duty to act. Section 455,671 is not a mandatory reporting statute. A Florida mental health professional cannot be sued successfully for failing to warn a third party. If all the conditions above are met, the psychologist may disclose to: the potential victim or a law enforcement agency Disclosures should be made only “to the extent necessary” to achieve the purpose of warning a potential victim so that the victim’s safety may be protected. A clinician will not be held liable for disclosing confidential information if acting in accordance with the provisions of Section 455.671. by Pamela H. Harmell, Ph.D.

 

As we are not equipped to give legal advice (this is a scope of practice issue for us as authors of this course) we recommend that you consult with an attorney if you have any legal questions.

There has been some clarification of the Tarasoff ruling. "An important note, if the patient is threatening to give someone a sexually transmitted disease, or any communicable disease, it is NOT defined as violence, if the sex will be consensual. If your patient has HIV or AIDS and threatens to have unprotected sex, there is no duty to warn, unless rape is intended." (Pelchat, Z., "Tarasoff for Clinicians: A User's Guide to the Law", November/December 2001, The California Therapist).

It is the clinician's responsibility to determine the seriousness of the threat and then notify the appropriate officials and intended victim.  It is important to seek legal counsel if you have a client with  potential Tarasoff issues.  Many professional organizations, such as the California Association for Marriage and Family Therapists, provide legal advice for their members.

See also California requires psychiatrists to warn about dangerous patients - Tarasoff v. Regents of University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976)  

Please continue to monitor professional publications, as rulings and interpretations of the laws do change, and this ruling may also be interpreted differently depending upon the state in which you practice. Check with a local attorney, or one recommended by your professional organization should you have a potential Tarasoff mandated breaking of confidentiality.

Report a person who "is a danger to others, or to himself or herself, or gravely disabled"

If our client is going to harm themselves or others we again have the responsibility for trying to keep them safe by informing the appropriate support people and possibly 5150 hospitalization. You must break confidentiality and arrange for a 72 hour involuntary hospitalization when a person "is a danger to others, or to himself or herself, or gravely disabled".
   

These are the clear issues of confidentiality .  How do you deal with issues in situations where you might see a client individually and in conjoint sessions?  How is this issue dealt with in schools where a teacher, principal or another school counselor might have been involved?  What if a concerned parent is demanding to know more?  What if the parent consistently walks into the room before the session is complete?   Again, a release of information and permission from the client are essential.  However, there is a certain energy that needs to be held in a therapeutic treatment that can be dissipated if  too much "sharing" happening.  As a rule the authors share as little as possible with outside referrals and are very protective of their client's information.  Most details of the case are omitted except where directly related to the clients' well being and safety.

In other settings you must also use your best judgment. Notes for hospital or clinic records are generally issue and goal oriented.  Schools do not usually require any type of clinical note beyond attendance.  Issues of confidentiality are paramount in the schools where a 'team approach'  is common among teachers and other helping professionals.  The same sense of protecting confidentiality does not often exist in the faculty room.  It is likely to be a delicate issue for the mental health provider.  It is good standard practice to acknowledge the colleagues good intent and concern but explain the issues around confidentiality in our profession.

4. I will be silent when it is time to be silent, protecting the sacred oath of confidentiality.

Honor Confidentiality
   The client must be assured that what they share in the therapeutic session stays within  the hour.  If you need to consult with outside people involved in the case you will need a release of information form signed in their records with a disclaimer for them to rescind permission in writing as well. The release of information must have an expiration date. You must inform the client of the times and circumstances in which confidentiality will be broken. These are the situations in which therapists are mandated by law to report. These include child abuse, elder abuse, and when a person "is a danger to others, or to himself or herself, or gravely disabled" (5150 and Tarasoff).
 

There are always questions that arise with regard to whether children may be treated without the consent of a parent or guardian.  The excerpt below outlines the general guidelines and limits for this decision.  It is important to note that it is always expected that the parent will be brought into the process of therapy unless you have very good justification for not making this choice.  This is an area in which you are advised to seek legal counsel for your particular client's considerations. Quoting Section 25.9 of the California Civil Code regarding the treatment of minors without parental consent on an outpatient basis, Richard Leslie clarifies the following limits:

 
One such limit is that the minor must be at least twelve (12) years of age and must, in the opinion of the attending professional person (licensed marriage, family and child counselors are included within the definition of "professional person"), be mature enough to participate intelligently in such outpatient mental health treatment or counseling.
Another limit involves the kind of problem the minor is experiencing. Only minors who fall within any one of the following categories may give consent without parental or guardian approval:

1. those who have been the alleged victim of incest or child abuse,
2. those who would present a danger of serious physical harm to himself/herself without such mental health treatment or counseling,
3. those who would present a danger of serious physical harm to others without such mental health treatment or counseling,
4. those who would present a danger of serious mental harm to himself/herself without such mental health treatment or counseling.

Because the word "serious" is not defined in the law, it is incumbent upon the practitioner to make his/her best clinical judgment at the outset. While many contracts by minors are voidable (able to be avoided because of minority - under 18 years of age), the consent given in this instance is not subject to disaffirmance because of such minority.( Richard Leslie, The California Therapist January/February 1990 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, San Diego, California.)
 

Do not report Domestic Violence -

In California -

WHO IS A "MANDATED REPORTER" OF DOMESTIC ABUSE?
If you are seeing an adult patient (<65) for a physical condition, and you find or reasonably suspect physical evidence of abuse, you are required to report, even if the patient denies abuse.

However, if you are seeing a patient for other consultation, such as a psychiatrist or a social worker, or if you are a pediatrician seeing a child as your patient, you are not required to report. Patient may choose to make their own report by contacting police.

Note this is different than required reporting about elder, dependent adult or child abuse, when simply hearing about abuse, without physical evidence, requires a report from any healthcare worker.

Keeping an adult safe is good therapy - but if we report DV, then people who are abused will not come to therapy!

In an article entitled "LMFTs Do Not Report Domestic Violence" Zachary P. Pelchat, Legislative Counsel of CAMFT states

Licensed Marriage and Family Therapists are not mandated reporters of domestic violence. If an LMFT reports domestic violence, it is a breach of confidentiality, regardless of the work setting or employer.... California Penal Code §11160(a) states that a health practitioner who is providing medical services for a physical condition is a mandated reporter. LMFTs do not provide services for physical conditions. Therefore, LMFTs do not report domestic violence. There is no exception for LMFTs in settings where physical health treatment is provided. There is no exception for LMFTs even if your employer has a different policy. No local policy of any agency or county takes precedence over state law.(This opinion was published in the January/February 2001 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California.

Please call your professional association for guidance and legal advice if you have a Tarasoff issue that regards domestic violence.

Psychotherapist-Patient Privilege

At its most basic, privilege is the right and duty to withhold testimony. This means that if you are subpoenaed, you must assert the psychotherapist-patient privilege on behalf of your patient unless your patient has requested that you do allow his/her records to be subpoenaed. The first thing to do is to contact your client, and let him/her know of the subpoena. Get a release of information so that you may talk to his/her attorney. It will be the attorney's job to 'quash' the subpoena, but DO NOT release any information on the client until you are certain that  Psychotherapist-Patient Privilege will not be invoked. There are certain cases in which Psychotherapist-Patient Privilege does not apply, most typically when the patient's mental or emotional condition is at issue, in which case all mental health records become relevant. It is not for the therapist to decide this however. Always assert the privilege and wait to see if the court rules on whether an exception applies.
 

We as therapists do not hold the Psychotherapist-Patient Privilege, but rather the client is the holder of the privilege, unless he or she has a guardian or conservator, then the guardian or conservator holds the privilege. If you are treating a group, family, or couple you must receive a waiver from each and every member of the group before you can release any information. If your patient is a minor child, he or she holds the privilege.

In June 1996, making a decision in the case Jaffee v. Redmond, the United States Supreme Court "recognized not only the importance of confidential communications to effective psychotherapy, but also the importance of psychotherapy to society as a whole. "The success of therapy depends on 'an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories and fears'." (From Supreme Court Ruling Upholds Psychotherapist-Patient Privilege by Billie Hinnefeld, Ph.D., J.D., and Karin D. Towers).
 

HIPAA compliant
Keeping patient records confidential is good therapy!

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addressed the security and privacy of health data. As the industry adopts these standards for the efficiency and effectiveness of the nation's health care system will improve the use of electronic data interchange. In this section, you will find educational materials to help you learn more about HIPAA.

HIPAA regulations mandate that all health care providers distribute a Notice of Privacy Practices to all patients. This document informs the patient of his or her rights and also outlines how their information may be used and shared without special written permission. We must also get a signed acknowledgement from the patient that he or she has received the Notice.

Vanderbilt University forms include the following

Notice (MC2740)

Notice-Spanish Version (MC2740-Spa)

Acknowledgement Form (MC2832)

Acknowledgement Form-Spanish Version (MC2832-Spa)

5. I will speak the truth.

Informed consent
 

Clients must know the reality and limitations of what they may expect. 

Inform your clients on your policies regarding:

payment
missed appointments
length of therapy
promptness
goals and techniques
implications of diagnosis
intended use of tests
legal responsibility of mandated reporting of abuse - when confidentiality will be broken
limitations of treatment
possible risks and benefits of treatment
intern status(if relevant)
your scope of practice and relevant expertise
signed and dated permission to release and exchange information
signed and dated parental permission to begin treatment with a child.

Providing informed consent is important for three main reasons. First, because patients have the right to consent to or refuse to consent to treatment, it is critical that they have sufficient information about the potential therapist and that therapist's policies, procedures and theoretical orientation so as to make that consent meaningful.
Second, informed consent, preferably in writing, assists patients and therapists in avoiding misunderstandings.
Third, it helps therapists in organizing their practices, and causes them to develop sound policies and procedures, as well as a rational approach to their businesses. ...Therapists should view informed consent as a continuing obligation. It should be revisited whenever there is a major change in the treatment approach, when the patient comes back to therapy after a reasonable or extended absence, when a new technique is introduced, etc. (Bonnie R. Benitez The California Therapist, the publication of the California Association of Marriage and Family Therapists, San Diego, November 2000)
 

Accountability

From our advertisements to our record keeping we are accountable to
ourselves
our clients
our malpractice insurers
our clients' insurers
Child Protective Services and other mandated reporting agencies
our licensing board
the profession

Accountability to malpractice insurers and licensing boards is dependent upon your state and type of license.  There are requirements for:

• record keeping
• ethical conduct
• legal responsibility
• continuing education

To be accountable to ourselves and our clients means we might say NO to a referral, if seeing the client is not in the therapist's best interests (i.e. the client's issues trigger your own too much for you to be present for the client)

or in the client's best interests (when the issues are beyond the scope of your practice, or you know you are not the best person for them to see. If you are dealing with your own addiction, you might want to refer an addict in recovery elsewhere.)

Record Keeping

If you didn't write it down, it didn't happen.

People lose licenses and are censured by their boards for not keeping notes of sessions.

In recent years the expectations regarding record keeping have markedly increased. Clearly stated goals, objectives, measurable outcomes, risks and benefits are among the items to be included.  Effective January 1, 2000, California's Business and Professions Code Section 4982 (v) stated that Failure to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered was unprofessional conduct. While these standards have not yet been legally clarified, looking over what is required in a summary can provide some guidance on what to include in your records.

In California, the HEALTH AND SAFETY CODE SECTION 123100-123149.5 states:

123130. (a) A health care provider may prepare a summary of the record, according to the requirements of this section, for inspection and copying by a patient. If the health care provider chooses to prepare a summary of the record rather than allowing access to the entire record, he or she shall make the summary of the record available to the patient within 10 working days from the date of the patient's request.

The summary shall contain for each injury, illness, or episode any information included in the record relative to the following:

• (1) Chief complaint or complaints including pertinent history.
• (2) Findings from consultations and referrals to other health care providers.
• (3) Diagnosis, where determined.
• (4) Treatment plan and regimen including medications prescribed.
• (5) Progress of the treatment.
• (6) Prognosis including significant continuing problems or conditions.
• (7) Pertinent reports of diagnostic procedures and tests and all discharge summaries.
• (8) Objective findings from the most recent physical examination, such as blood pressure, weight, and actual values from routine laboratory tests. (Please keep in mind that this applies to all health professionals, so certain sections, such as (8) won't apply to most mental health professionals.) For a complete copy of this code please go to http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=

123001-124000&file=123100-123149.5) Other items to keep track of include:

• Intake form completed by the patient or therapist, including the referral source if known.  (Please check with your professional organization for sample intake forms, as these differ by state and professional license.)
• Release of information forms, copy of written authorization to treat, disclosure statement and/or informed consent by the patient or his/her parent(s)
• Copy of release to insurance company for reimbursement. (The HCFA-1500 form contains the following: "READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE. I authorize the release of any medical or other information necessary to process this claim.")
• Dates of treatment
• Fees charged and information, if it exists, on obtaining reimbursement from third party payers
• Therapeutic goals of patient/therapist
• Any changes to the treatment plan
• Copies of any assessments or psychological testing administered to patient
• Detailed information when a red flag issue appears, such as suicidal ideation; Tarasoff situations; 5150 episodes in which the client is in need of involuntary hospitalization, mandated child, elder or dependent adult abuse reporting, etc.
• Detailed notes on interventions when working with a borderline client
• Any other notes regarding confidentiality (for example, if the client does not want you to leave phone messages or send bills to a specific address, etc.)

I have a simple system for record keeping: a large binder which has a zipper. The dividers are alphabetized, and each client has their own page. I keep track of each session by turning to the client's page, and I enter the date after the previous session. I jot a few notes, which I then review prior to their next session. This allows me to recall content, dreams, etc. Any important issues (transference reactions, red flags, etc.) I put in the margin so that I can easily find them. I keep my notes in order to be a better therapist, not to protect myself in the event of a subpoena. When the binder gets too full, I take out the pages and file them in each client's folder. The binder stays in my file cabinet, in my office, both of which are locked when I am not there. (The double lock rule is a good one; records are accessible only after opening two locks, such as the file cabinet and the office door.) If you transport your notes, make sure that you do not have clients identified by their first and last names for reasons of confidentiality should the notes get lost.

If you keep your records electronically, make sure you are following the HIPAA guidelines. It is prudent practice to have your records password protected, and encrypted if you use an online record storage system.

In California there are no legal standards for how long notes should be kept by individual therapists. Licensed health facilities and community care facilities must keep records for seven years, or, in the treatment of a minor child, seven years after the patient reaches the age of 18. If you do destroy notes, make sure that they are disposed of in a manner that respects patient confidentiality. Some therapists now are writing "Professional Wills" that specify what is to be done with their records in the event of their death. We recommend that you consult with your professional organization for guidance in this matter.

Truth in advertising

Most licensing boards have very specific criteria for advertising; what must be included, and what you may not say. In California law, Section 651 of the Business and Professions Code (B & P Code), states that it is unlawful for any person licensed under Division 2 of the Business and Professions Code ( MFTs, LCSWs, psychologists, psychiatrists and other health care providers):
"..to disseminate or cause to be disseminated, any form of public communication containing a false, fraudulent, misleading, or deceptive statement or claim, for the purpose of or likely to induce, directly or indirectly, the rendering of professional services or furnishing of products in connection with the professional practice for which he is licensed."

False, misleading or deceptive advertising can be prosecuted as a criminal offense, and can result in license suspension or revocation by the Board of Behavioral Science Examiners. Please check with your licensing board and professional organization for specifics for your license.

Please go to the APA Code of Ethics for guidelines on advertising.

6. I will be respectful.

Respecting diversity is an important part of ethics, whether it be respecting:

differently-abled people

people from cultures different that your own

people who are older or younger than you are

people who worship a different God

people who are a different gender than you are

people who love people of different gender than the ones you love

Be Aware!

Be Respectful

Don't ever think we are all the same ...we aren't!

(1) Within what framework or context can I understand this client (assessment)?
(2) Within what context do client and counselor determine what change in functioning is desirable (goal)?
(3) What techniques can be used to effect the desired change (intervention)?

Click here for more on Multicultural Counseling. A new window will open.

Please go here for "Internationalizing the counseling psychology curriculum: Toward new values, competencies, and directions". Anthony J. Marsella and Paul Pedersen. Counselling Psychology Quarterly. Volume 17 Number 4 (December 2004), 413-423.

Please go to Culture and Psychopathology: Foundations, Issues, and Directions. Anthony J. Marsella and Ann Marie Yamada, (2007) Handbook of Cultural Psychology, Edited by Shinobu Kitayama, Dov Cohen, Guilford Press

7. I will know myself, my abilities and my limits.

Competency and Scope of Practice

A simple question to ask yourself is: Do I have the tools, skills and expertise necessary to effectively treat this client? 

The other question to consider is: Is this a clinical issue that can be treated effectively within the scope of practice as defined in my licensure code of ethics?   For example in many states having the license to do clinical social work, family therapy or professional counseling does not allow the laying on of hands for healing.  This modality would require an additional license in medicine or massage therapy. In many instances you may be well advised to keep a dual relationship of massage and psychotherapy separate. Again, if this is relevant to you, consult with an attorney. In an article by Richard Leslie the following is stated,

For instance, this question is often asked: "I am a massage technician. Can I also do psychotherapy with my massage clients and visa-versa?" My answer is usually "no." If a massage client needs therapy, refer him/her elsewhere. If your therapy client needs bodywork, refer him/her elsewhere. Each business should be conducted separately in order to avoid legal or ethical problems. ("Dual Relationships - The Legal View", September/October 1999 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists)

In general, if you receive a referral for which you have no practical knowledge or experience it may be best to refer the client to a fellow therapist. If you feel able to work with the client seeking outside consultation would be essential.

There is no easy formula to apply that will help therapists decide where the lines are to be drawn. If one wants to avoid trouble or risk, the rule is simple. Avoid all dual relationships with patients or ex-patients. Play it safe. For those who do not ascribe to so strict a rule of conduct, you must carefully analyze each situation, and perhaps seek assistance from others, e.g. lawyers and clinicians. (Richard Leslie, "Dual Relationships - The Legal View" September/October 1999 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists)

Have emergency information on your phone message

The California Department of Managed Care (formerly the Department of Corporations) now requires that your phone message, after hours, directs patients to the nearest emergency room if they believe they are having an emergency. The simplest way to accomplish this is to add to your phone message:

"If you believe this is a life threatening situation, please hang up and dial 9-1-1 or go to the nearest emergency room" (or a community mental health center if there is one that provides 24 hour care.)

8. I will ask for help when I need it, and acknowledge when I don't know something.

Use Consultation

Within each discipline there are specific issues that you may need to refer to another professional for collaboration.  For instance if your client is presenting a physical complaint for which they say there has been no diagnosis, it is still imperative that you consult with the physician treating the client.  It is not within our scope of practice to determine that a symptom is exclusively psychosomatic.  When it appears that a client may have a diagnosis requiring medication,  consultation with a psychiatrist is necessary and beneficial.  Working in collaboration with other professionals who respect the boundaries of each treatment provides the client and clinician with the best possible scenario for healing.

Certain legal issues may require an attorney's knowledge and expertise.  Therapists cannot presume to answer legal questions of malpractice, divorce or custody issues, property damages, or any other legal issues.  Even if you have had personal experience with these issues laws, specific issues and mandates are often subject to change.  In these cases make sure to recommend legal counsel .  For therapists,   the more complex issues involving abuse, Tarasoff, domestic violence and suicide can sometimes be aided by a lawyer's protection.  Most professional organizations like CAMFT have legal help available to their members.  

Be familiar with your Licensing Board's Code of Ethics

It is imperative that you be familiar with the requirements for your particular state and license. If you cannot find the information you need by following the links we have provide make sure to call your Board with specific question.

Please search NOW for your state licensing board. .go to a search engine, like Google.com, and type in what you are looking for; put " quotation marks " around phrases that you want together. Put a + if you want it included, and a - if you want something excluded.

An example is: California +psychologist +"Code of Ethics"

Continue to learn

If we stop learning, we stop growing. As a CEU provider, it is joy to get feedback on my courses. I know there are many of us who grit our teeth and muscle through the courses, trying just to pass the tests so we can get the certificates. Yet I do hope that we are not so arrogant as to think we know it all, or don't need to learn anything new.

Did you know? For the Board of Behavioral Sciences, the most common violations subject to citation and fine are: 1. Failure to Comply with Continuing Education Requirements 2. Unlicensed Practice 3. Breach of Confidentiality

  9. I will give back, and strive to make my presence be a healing one in the world.

This refers to the fact that we, in the healing professions, have so much we can contribute. Whether it be through volunteering, or a sliding scale, or working with the dispossessed, we can provide services to those who otherwise could not afford therapy.

We also can strive to make our presence be a healing one in the world. this refers to the amount of bickering and contention that often arises when a group of therapists form an organization. We can be so good at creating drama, or one-upping others, that we lose sight of the prize.

It's not about you ALL the time, only some of the time!

Know when to leave your ego at home.

10. I will take care of myself, so that I can take care of others.

Practice Self Care
A very important consideration we must make as therapist is identifying when we may be approaching burnout.  We are responsible for taking care of ourselves!  We cannot do good therapy if we are exhausted, frustrated, overemotional or despondent. 

  
Please go seek therapy throughout your life! This activates healing within you, with in turn promotes healing within your patients, and people in your life.  This is the archetype of the Wounded Healer, a concept originating in Ancient Greece, with the myth of Chiron. Chiron was a centaur, a healer who himself had an incurable wound. In psychotherapy, if we are conscious of our own wounds, we are less likely to project them onto our clients. This impacts the energetic field of therapy; if we are working on our own woundedness, this constellates hope in our patients that they too may access their own inner healer.

Also, it is important to remember to laugh at yourself!

Understand and take care of yourself

so that you may take care of others.  

If you feel that you cannot work with someone for any reason the only thing to say is "No."

If your work with someone is stuck, get consultation!

Do not be afraid to say, "I don't know"

Physician, heal thyself!

Therapist, know thyself!

  When using this course as a guide, be aware that laws, regulations and professional standards change over time. Therapists should verify and update any laws, regulations, references or information contained in this course. This course is intended to provide guidelines for examining difficult ethical legal dilemmas. We did not address every situation that could potentially arise, nor is this course a substitute for independent legal advice and consultation. Please consult with your licensing board, professional association or an attorney for ethical and legal advice.

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