A 10-year-old boy has been described as having disruptive behavior at home and at school. Below are five different scenarios in which I am challenged to explore and apply the knowledge I have gained throughout this course in making ethical and legal decisions.
Scenarios
Scenario 1.
The mother informs you that a family physician that recently diagnosed her son with a Sleeping Disorder would like to know more about the boy’s therapeutic work and his success in therapy. The mother informs you that the physician will contact you shortly. Explain how you will treat the mother’s request to establish communication with the physician in light of the therapeutic mandates for privacy and confidentiality.’
Throughout your career as a marriage and family therapist, you will find yourself not only working with other mental health professionals but also other healthcare providers such as a family’s primary care physician or specialist. Even when consulting other healthcare professionals, it is important to remain ethical and legal in your work. The AAMFT, CAMFT, and other codes of ethics are specially designed to give mental health professionals the tools to avoid legal and ethical danger presented by the government, other professionals, and the public (Wilcoxon, Remly, & Gladding, 2014, p 44).
In this specific scenario, I am dealing with a minor and his legal guardians and it is very important that we abide by the confidentially and consent standards outlined in the CAMFT and AAMFT. The boy’s parents are requesting that you release personal and confidential information to a third party, and it is important to follow the necessary steps. Section 2.2 of the AAMFT states that therapists must obtain written authorization or a waiver from the client in order to disclose personal and confidential information (American Association of Marriage and Family Therapy [AAMFT], 2015, Section 2.2). Confidentiality is one of the more unique situations marriage and family therapists encounter in their careers, as their therapeutic relationship may include more than one person (AAMFT, 2015, Section 2). Client confidentially is very important and has the potential to make or break your career and your relationships with clients. In situations that concern minors, you also have legal guardians to consider. In this scenario, it seems as though the boy’s mother is giving verbal authorization to release her son’s information to their family physician. However, verbal authorization is not sufficient, except in emergency situations. (AAMFT, 2015, Section 2.2). You must let the boy’s mother know that you would be happy to discuss her son’s progress with their family physician but will not do so until written authorization has been received. If the boy’s mother gives you any pushback about obtaining written authorization, it is important to reassure her that you are abiding by the law and protecting her son’s personal and confidential information.
Scenario 2.
One day your client comes to the session and tells you that if he refuses to go to bed at a certain time, his father closes him in a bathroom for the rest of the night and does not give him anything to eat the next morning. Describe your actions in light of your obligations as a mandated reporter.
Dealing with children in a therapeutic setting can be difficult at times. There is always the possibility that the children you see in therapy are subjects of abuse and/or neglect. It is your job as a mandated reporter to recognize when a child is in danger and report it to the appropriate officials. California Penal Code §11166 states, that as a mandated reporter, you must make your “initial report by telephone to the agency immediately or as soon as is practically possible, and shall prepare and send, fax, or electronically transmit a written follow up report within 36 hours of receiving the information concerning the incident” (Child Abuse and Neglect Reporting Act, 1987). When interacting with children, you will also be interacting with their parents/legal guardians. It is important that you, as a therapist, look out for the child and his/her well-being. Coming between a child and their parents/legal guardians can be very difficult and uncomfortable, but as a mandated reporter you will occasionally find yourself in uncomfortable situations and they must be handled ethically and legally.
In this scenario, my client brings to my attention that his father locks him in the bathroom if he refuses to go to bed and does not provide him breakfast the next morning. In this scenario, the father is neglecting to do his job as a parent and provide for his son and make sure he is taken care of. Children can be difficult at times, but we cannot lock them away and deny them nourishment when they act out. Leaving a 10-year-old alone, unsupervised in a bathroom overnight, is a form of neglect. Not providing a meal to a child, is a form of neglect. As a mandated reporter, I am required, by law to report this as a suspected case of child neglect. I must report this to either Child Protective Services or the local police department over the telephone and I would have 36 hours to follow up in writing. Failure to report the suspected neglect to the relevant authorities is a misdemeanor and as a result, you can spend six months in jail and/or be fined one thousand dollars (Child Abuse and Neglect Reporting Act, 1987).
Scenario 3.
One day you conduct a family session: the boy, the mother, and the father are all present. After the session, you realize that your client’s father was your parents’ lawyer. Discuss your possible actions and remember Standard 1.3 from the AAMFT Code of Ethics and the first standard in the CAMFT Code of Ethics.
Standard 1.3 of the AAMFT code of ethics clearly states that “Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons” (AAMFT, 2015). Standard 1.2 in the CAMFT states that marriage and family therapists are to “avoid dual relationships with patients that are reasonably likely to impair professional judgment or lead to exploitation (California Association of Marriage and Family Therapists [CAMFT], 2011). Both standards highlight the importance of avoiding multiple/dual relationships with your clients.
In this scenario, I find out later on, that my client’s father was my parents’ lawyer. This can be seen as having multiple relationships because I share a close relationship with my parents’ lawyer, and I am providing care as a therapist to his son. This has the potential to lead to conflict between me and my client’s father. However, in this particular scenario, I did not find out about the multiple relationships until after my first session with the boy. Since it did not impact my first session with the boy, it is my responsibility to remain professional and ethical moving forward, even with the dual relationship. Self-reflection is going to play a large role in my decision to move forward with treating the boy and working with his parents. If I am honest with my self-reflection and decide that the relationship, I have with my client’s father will not interfere with the legal and ethical care I provide, I can move forward with seeing him. If I decide that the relationship will interfere with the legal and ethical care I provide, I have the right to reach out to collogues and supervisors to decide what will need to be done to make sure my client receives the care he deserves. In some cases, this could mean passing my client off to another therapist, and if it comes to that, it must be done up to the legal and ethical standards laid out in both the AAMFT and CAMFT. As mental health professionals, it is our responsibility to “emphasize the fundamental priority of client welfare and the significance of therapist competence, due care, and impairment in fulfilling that priority” (Wilcoxon, Remly, & Gradding, 2014, p 42).
Scenario 4.
Ten sessions into the therapy, your client's mother informs you that their insurance panel did not approve further treatment. Discuss your actions, keeping in mind Standard 1.11 from the AAMFT Code of Ethics and the ninth standard in the CAMFT Code of Ethics.
Section 1.11 of the AAMFT highlights the importance of not abandoning your clients in treatment “without making reasonable arrangements for the continuation of treatment” (AAMFT, 2015). No matter the scenario, therapists have a professional responsibility to care for their clients and make necessary arrangements should certain situations occur. In this scenario, my client's mother informs me that their insurance will not cover any more treatment. As discussed previously in this course, as mental health professionals, we will have to deal closely with insurance companies and abide by their guidelines. It is important that we abide by these guidelines, as it could cost both therapist and client more money than necessary.
In this scenario, I would not abandon this family, I would discuss the need to make other arrangements that best suit their own needs and abide by their insurance company’s guidelines. I would go over other services they could use that their insurance company may partially, or fully cover. One of the most difficult parts of this scenario is letting the family know we would need to terminate our therapy sessions and refer them to other providers. It is my job to prepare them for this transition and make sure the transition itself is smooth. It is important that I remain ethical and abide by all legal standards set for me by the state. I will not release any patient information in my transition without written consent and will not make any suggestion that is unreasonable or unobtainable to my client. The financial aspect of all health care is a stressful topic, and as a professional who deals closely with both sides of the spectrum, I can help facilitate a stronger understanding, and attempt to put my clients’ minds at ease.
Scenario 5.
One year after the termination of the therapy, you receive a subpoena from the mother’s lawyer asking you to be part of the court proceeding following the parental divorce of your client. Describe your actions.
After my discussion with Samantha White a few weeks ago, I feel more than prepared to deal with a scenario such as this one. I was told to always treat my case notes as if they could be subpoenaed at any moment. In this scenario, my first thought is to consult legal counsel, colleagues, and superiors. As mentioned by Benjamin Caldwell in his User’s Guide to the 2015 AAMFT Code of Ethics, “If a therapist receives a subpoena requesting records to be sent to an attorney regarding a patient or requesting the therapist's appearance at the deposition or court hearing, it is recommended that the therapist consults with the client to determine the client’s wishes and contact an attorney (2015, p 53). For the sake of reiteration, section 2.2 of the AAMFT code of ethics states that I must obtain written authorization from my client before releasing any client information (AAMFT, 2015, Section 2.2).
It is extremely important to protect my client’s confidentiality above all else. I have spent a significant amount of time talking to my client, my client’s mother, and my client’s father. Therefore, I would have to also ask both mother and father to give me written authorization to release their information. It is my responsibility to release only the information that is relevant to the case, nothing more and nothing less. The law requires that I comply with the subpoena, and failure to do so is punishable as contempt. I must make my clients aware of my legal responsibility in these circumstances but ensure them that I will do so ethically. I will remind my clients that their confidentiality is important to me and will not share any more than needed. I will also put my client's minds at ease by letting them know, I make it a point to be prepared for situations like this from the moment we began our sessions. Reassurance can be very important in situations like these because of how stressful going to court can be for all parties involved.
Client Notes: SOAP
The SOAP note format allows therapists to clearly and thoroughly document a client’s progress (Cameron & Turtle-Song, 2002). It is required that I accurately and clearly notate everything I do with my clients to ensure a smooth therapeutic process. Being organized can make or break a client’s experience with you and can ultimately help them build a stronger relationship with you. Clients want to make sure you are fully engaged in them and their situations and remaining organized can help you do so. Not only does the SOAP format help your clients, but it can also help colleagues and supervisors better understand your process.
There is a total of four components that make up the SOAP note format: subjective, objective, assessment, and plan. The subjective component “contains information about the problem from the client’s perspective and that of significant others (Cameron & Turtle-Song, 2002). This component really explores your client’s feelings and goals. The objective component is going to be your observations, which can include physical and interpersonal information (Cameron & Turtle-Song, 2002). The assessment component is going to be the summary section of your thoughts and ideas in regard to your client’s problem(s) (Cameron & Turtle-Song, 2002). Finally, the last component of the SOAP format is the plan. The plan component is the detailed description of your action plan, treatment progress, and treatment goals for your client (Cameron & Turtle-Song, 2002).
An example of the SOAP method based on the given vignette is as follows: 12/07/2019 4:00 pm. (S) The client is showing behavioral issues at home and school. Father has been known to emotionally abuse and neglect the client. Parents are getting a divorce. The client has a history of a sleeping disorder. (O) The client appears to be acting out due to rage, fear, and sadness. (A) Neglect of a child by a father (DSM-IV-TR V61.21). Aggressive behavior with instances of anger. Emotional triggers from parents getting divorced. (P) Continue with behavioral therapy. The next session is scheduled for 12/11 at 2:00 pm.
References
American Association for Marriage and Family Therapy. AAMFT Code of Ethics (2015). Retrieved from: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: Author.
Caldwell, B. E. (2015). Users guide to the 2015 Aamft code of ethics. Alexandria, VA: American Association for Marriage and Family Therapy.
California Association for Marriage and Family Therapy. CAMFT Code of Ethics. (2011). Retrieved from: http://www.camft.org/images/PDFs/CodeOfEthics.pdf
Child Abuse and Neglect Reporting Act, Cal. Penal Code § 11166 et seq.
Cameron, S. & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80, 286-292.
Wilcoxon, A., Remly, T., & Gladding, S.T. (2014). Ethical, legal, and professional issues in the practice of marriage and family therapy. 5th ed. Upper Saddle River, N.J: Pearson Merrill Prentice Hall.