Wednesday, April 28, 2004
Ethics final exam
Part A.
1. B - as I recall in the emerich case the attempt at warning was not sufficient.
2. C
3. E
4. E
5. Never, because once you have you license you will never do any harm. I have no idea. Points for sarcasm?
6. C
7. A
8. C, but with feedback and explanation
9. B
10. D
Part B:
I believe that the best action to take in this case is to offer 4 additional sessions to the client over one month prior to termination of therapy (this is chronologically consistent with the 30 days of emergency treatment offered by Dr. Greene). Also like the M.D. I would offer the client a referral to a colleague, with the option of my consulting with the new therapist to assist in transition. This of course would include appropriate consent and release of information from the client. My rational for this course of action is not for the purposes of protecting Dr. Greene's practice, but instead to consider what is in the best interest of the client and what potential future insurmountable difficulties could arise in the therapeutic relationship.
As an alternative, I had considered taking the patient as a private client in an effort to benefit him and as the ethics code states to first do no harm. There is an ethical responsibility first to the client, and considering that Dr. Greene terminated medical treatment (not the client), I think that the client does perhaps have the right to continue mental health care from me. However, when considering the specifics of the ethics code as well as foreseeable future difficulty, it appears that the best course of action would be to terminate treatment.
First I assume that when considering providing treatment through an organization part of informed consent would include the structure and boundaries of treatment. The ethics code states that the boundaries of treatment need to be defined at the onset of the intervention, specifically in regards to working through an organization. With the information provided in the vignette, it appears that my role is to "provide support, counseling, and assessment services" as part of treatment on a "treatment team". My continuing to see the client privately appears to break what appears to be the initial treatment agreement in that he was receiving services as part of his treatment for cancer.
An additional ethical consideration is in regards to conflict of interest. This comes into consideration because of the law suit. Both my employer and my client stand to benefit from the outcome of the lawsuit, and as the therapist I would be in the middle of that conflict. The outcome of this could be extremely difficult because the client might assume that I have an invested interest in the oncology practice that he is suing and may attempt to influence his decision regarding the law suit. In addition if called as a witness I would be in a position to perhaps decide if in indeed there was malpractice. Also if the client lost the case, I assume this might undermine his future treatment. Treatment in general may shift away from topics regarding his mental and physical health, and move towards the lawsuit. Also in regards to confidentiality I might be put in a position to reveal the content of treatment sessions for purposes of the lawsuit. In addition I would have to keep information from the practice confidential from my client. This would also negatively effect the therapeutic alliance.
Worth noting in my decision, although perhaps influenced by my personal value system, is the idea that the client never shared with me his intent to sue Dr. Greene. If the therapeutic alliance was adequately strong I would assume that the client would have discussed his malpractice lawsuit with me. This does not appear to be the case. Lastly, if he did not share this information it seems that I might also be susceptible to a future lawsuit whether it is justified or not.
Part C.
The take home message: Despite the seemingly obvious content of the ethics code, when applied to clinical practice it needs to be thoroughly considered and observed or one may quickly find themselves sliding down the slope of indiscretion and poor judgment.
In addition what I was able to take home was a process of ongoing examination of my own system of ethics and the potential hypocrisy in my thinking and behavior in regards to ethics. This is not to say that I vacillate between ignorance and rigidity, but clearly I find myself needing to reevaluate my decision making on a case to case basis. As the preparadigmatic state of psychology continually shifts to finalize its place effective health care, the ethics code is also shifts as law and rights become more defined. This includes rights of both client and therapist. As a therapist the ethics code exists to protect me from not only from law suits, but from making poor judgments. Clients need to be protected from poor judgment, but also from entering into a relationship that demands intimacy but does not insulate from harm. The ethics code becomes insulation, not necessarily protection, from the harm of exploitation. As clearly stated the specifics of the ethics code and hopefully my future practice are formed around the essential concepts of beneficence, non-maleficence, fidelity, responsibility, integrity, justice, and respect for people's rights and dignity. Also I shouldn't have sex with my clients.
Part A.
1. B - as I recall in the emerich case the attempt at warning was not sufficient.
2. C
3. E
4. E
5. Never, because once you have you license you will never do any harm. I have no idea. Points for sarcasm?
6. C
7. A
8. C, but with feedback and explanation
9. B
10. D
Part B:
I believe that the best action to take in this case is to offer 4 additional sessions to the client over one month prior to termination of therapy (this is chronologically consistent with the 30 days of emergency treatment offered by Dr. Greene). Also like the M.D. I would offer the client a referral to a colleague, with the option of my consulting with the new therapist to assist in transition. This of course would include appropriate consent and release of information from the client. My rational for this course of action is not for the purposes of protecting Dr. Greene's practice, but instead to consider what is in the best interest of the client and what potential future insurmountable difficulties could arise in the therapeutic relationship.
As an alternative, I had considered taking the patient as a private client in an effort to benefit him and as the ethics code states to first do no harm. There is an ethical responsibility first to the client, and considering that Dr. Greene terminated medical treatment (not the client), I think that the client does perhaps have the right to continue mental health care from me. However, when considering the specifics of the ethics code as well as foreseeable future difficulty, it appears that the best course of action would be to terminate treatment.
First I assume that when considering providing treatment through an organization part of informed consent would include the structure and boundaries of treatment. The ethics code states that the boundaries of treatment need to be defined at the onset of the intervention, specifically in regards to working through an organization. With the information provided in the vignette, it appears that my role is to "provide support, counseling, and assessment services" as part of treatment on a "treatment team". My continuing to see the client privately appears to break what appears to be the initial treatment agreement in that he was receiving services as part of his treatment for cancer.
An additional ethical consideration is in regards to conflict of interest. This comes into consideration because of the law suit. Both my employer and my client stand to benefit from the outcome of the lawsuit, and as the therapist I would be in the middle of that conflict. The outcome of this could be extremely difficult because the client might assume that I have an invested interest in the oncology practice that he is suing and may attempt to influence his decision regarding the law suit. In addition if called as a witness I would be in a position to perhaps decide if in indeed there was malpractice. Also if the client lost the case, I assume this might undermine his future treatment. Treatment in general may shift away from topics regarding his mental and physical health, and move towards the lawsuit. Also in regards to confidentiality I might be put in a position to reveal the content of treatment sessions for purposes of the lawsuit. In addition I would have to keep information from the practice confidential from my client. This would also negatively effect the therapeutic alliance.
Worth noting in my decision, although perhaps influenced by my personal value system, is the idea that the client never shared with me his intent to sue Dr. Greene. If the therapeutic alliance was adequately strong I would assume that the client would have discussed his malpractice lawsuit with me. This does not appear to be the case. Lastly, if he did not share this information it seems that I might also be susceptible to a future lawsuit whether it is justified or not.
Part C.
The take home message: Despite the seemingly obvious content of the ethics code, when applied to clinical practice it needs to be thoroughly considered and observed or one may quickly find themselves sliding down the slope of indiscretion and poor judgment.
In addition what I was able to take home was a process of ongoing examination of my own system of ethics and the potential hypocrisy in my thinking and behavior in regards to ethics. This is not to say that I vacillate between ignorance and rigidity, but clearly I find myself needing to reevaluate my decision making on a case to case basis. As the preparadigmatic state of psychology continually shifts to finalize its place effective health care, the ethics code is also shifts as law and rights become more defined. This includes rights of both client and therapist. As a therapist the ethics code exists to protect me from not only from law suits, but from making poor judgments. Clients need to be protected from poor judgment, but also from entering into a relationship that demands intimacy but does not insulate from harm. The ethics code becomes insulation, not necessarily protection, from the harm of exploitation. As clearly stated the specifics of the ethics code and hopefully my future practice are formed around the essential concepts of beneficence, non-maleficence, fidelity, responsibility, integrity, justice, and respect for people's rights and dignity. Also I shouldn't have sex with my clients.
Wednesday, April 14, 2004
The Tuskegee experiment clearly sets the standard for unethical research, however having subjects play prisoner and guard roles in a university basement is not far behind. Telling people that they are delivering shocks to a stranger to test a hypothesis regarding conformity is also in the same boat. The question remains about how deceptive a researcher can be and at what cost. It appears that the experiment regarding the diffusion of responsibility on the subway is wholely unethical because it is extremely disruptive to peoples lives if not potentially traumatic.
Appropriate to the discussion is information made public recently regarding Kitty Genovese. Evidently Ms. Genovese was a lesbian and as per her girlfriend the people in the apartment complex generally did not condone her sexual orientation. Was this perhaps a confounding variable that needs to be considered in experiments testing the diffusion of responsibility?
Lastly-
If the electrodes in the cats heads hurt them I think we ought not do that type of experiment, however I do eat meat and wear leather so maybe ethical guidelines regarding animal testing are as arbitrary as my own.
Appropriate to the discussion is information made public recently regarding Kitty Genovese. Evidently Ms. Genovese was a lesbian and as per her girlfriend the people in the apartment complex generally did not condone her sexual orientation. Was this perhaps a confounding variable that needs to be considered in experiments testing the diffusion of responsibility?
Lastly-
If the electrodes in the cats heads hurt them I think we ought not do that type of experiment, however I do eat meat and wear leather so maybe ethical guidelines regarding animal testing are as arbitrary as my own.
Wednesday, April 07, 2004
Answers to homework: 1. A, 2. A, 3. D, 4. C, 5. D
Reaction to the website: Hidden tape recorders? Evaluator will conclude that client has brain damage because the client groans? 4 sex images = schizophrenia? Homosexual responses? Vulver fixation? Castration anxiety?
Articles: Lewin strikes again. I continue to observe the essential element of feedback in many interventions, both empirically supported and unsupported alike. Why not in assessment also. It is a stretch, however to say that assessment feedback is a "brief intervention".
Chap. 12: I will only take issue with two points. First (briefly) what constitutes an outdated measure?
Second, the chapter offers a vignette where a psychologist state to the court that he is unable to come to a conclusion regarding the parental competence of a person whose child is in foster care. This biological parent no longer lives at the last listed address with the department of human services. The psychologist was supposed to interview the parent specifically in order to determine whether the parent was fit for visitation with the child. Is it not the duty of a psychologist to come to a conclusion with the information that is available? Of course informing those involved that additional information was not available at the time. Maybe this is an attribution error, but if a parent has a child in foster care should they not be responsible for providing appropriate contact information to those that are caring for his or her child? Could one easily conclude that the parent is in fact unfit for visitation. In my own experience as a foster care case worker I have found that inconsistent parental visits are more distressing to a child than no visits at all.
Reaction to the website: Hidden tape recorders? Evaluator will conclude that client has brain damage because the client groans? 4 sex images = schizophrenia? Homosexual responses? Vulver fixation? Castration anxiety?
Articles: Lewin strikes again. I continue to observe the essential element of feedback in many interventions, both empirically supported and unsupported alike. Why not in assessment also. It is a stretch, however to say that assessment feedback is a "brief intervention".
Chap. 12: I will only take issue with two points. First (briefly) what constitutes an outdated measure?
Second, the chapter offers a vignette where a psychologist state to the court that he is unable to come to a conclusion regarding the parental competence of a person whose child is in foster care. This biological parent no longer lives at the last listed address with the department of human services. The psychologist was supposed to interview the parent specifically in order to determine whether the parent was fit for visitation with the child. Is it not the duty of a psychologist to come to a conclusion with the information that is available? Of course informing those involved that additional information was not available at the time. Maybe this is an attribution error, but if a parent has a child in foster care should they not be responsible for providing appropriate contact information to those that are caring for his or her child? Could one easily conclude that the parent is in fact unfit for visitation. In my own experience as a foster care case worker I have found that inconsistent parental visits are more distressing to a child than no visits at all.
Wednesday, March 31, 2004
Answers: 1.D, 2.A, 3.D, 4.B, 5.C
I attempted to restrain my initial visceral reaction to the prediction and diagnosis article because I thought that the author might at some point make a useful argument for empirical support in diagnosis and maybe psychotherapy. I also considered that I was reacting negatively because the profession I chose and perhaps my individual judgment was being called into question. But after the author's discussion of school performance, brain injury, criminal behavior, hodgkins disease, heart attacks, and bankruptcy I allowed myself to be annoyed and disgusted when he did not attempt to back up his insinuation that the knowledge and judgment of a well trained psychologist is less valuable in diagnosis that quantifiable elements of patients. Yes, quantifying variables to make predictions is valuable. Yes, predictability is always helpful. But, how does the author dare touch the concept of "gestalt" and not discuss treatment. There is a reason I am going to be a psychologist not an actuary.
In regards to the Interpersonal Website:
I'm a big fan of Sullivan. Anyhow, the interpersonal complementary (spelling?) is currently applied in McCullough's CBASP treatment for chronic depression and plays a significant role in treatment. McCullogh refers to this as the transferrence hypothesis. Specifically McCullough warns that a submissive patient will pull for dominance in the therapist.
Pertaining to supervision:
One of my co-workers was a supervisor of mine at a practicum site. This has caused some tension, especially because my judgment is as valid as his in our current setting. I might be applying to an internship site where he will be on the admissions committee. Not a good situation, but is the type of thing that can arise and become an ethical issue for both he and I.
I attempted to restrain my initial visceral reaction to the prediction and diagnosis article because I thought that the author might at some point make a useful argument for empirical support in diagnosis and maybe psychotherapy. I also considered that I was reacting negatively because the profession I chose and perhaps my individual judgment was being called into question. But after the author's discussion of school performance, brain injury, criminal behavior, hodgkins disease, heart attacks, and bankruptcy I allowed myself to be annoyed and disgusted when he did not attempt to back up his insinuation that the knowledge and judgment of a well trained psychologist is less valuable in diagnosis that quantifiable elements of patients. Yes, quantifying variables to make predictions is valuable. Yes, predictability is always helpful. But, how does the author dare touch the concept of "gestalt" and not discuss treatment. There is a reason I am going to be a psychologist not an actuary.
In regards to the Interpersonal Website:
I'm a big fan of Sullivan. Anyhow, the interpersonal complementary (spelling?) is currently applied in McCullough's CBASP treatment for chronic depression and plays a significant role in treatment. McCullogh refers to this as the transferrence hypothesis. Specifically McCullough warns that a submissive patient will pull for dominance in the therapist.
Pertaining to supervision:
One of my co-workers was a supervisor of mine at a practicum site. This has caused some tension, especially because my judgment is as valid as his in our current setting. I might be applying to an internship site where he will be on the admissions committee. Not a good situation, but is the type of thing that can arise and become an ethical issue for both he and I.
Wednesday, March 17, 2004
1-A, 2-B, 3-B, 4-C, 5-D, 6-C, 7-C, 8-D, 9-D, 10-B, 11-B, 12-C
Regarding the article I was surprised to see how many therapists had attended a client's social event such as a wedding. This does not at all reflect how our class answered the survey that was provided during the duel relationship discussion. One might imagine that most of the responders in the study were not attending the social events to serve in a therapeutic role.
Having looked over Pope's web sight blogging is beginning to make a lot of sense. As we discuss the dissemination of information, perhaps web site information will be the key to information sharing in EST's ethics etc. What way could possibly be faster in disseminating info?
(p.117 of ethics text)- Mabye I am confused. The text states that a patient can request to have information in their file changed, but only if the psychologist deems the changes to be appropriate. I am assuming the client is asking the psychologist to make changes in the notes that the psychologist created. Do clients have that power and is so doesn't this create conflict? In addition why would a psychologist decide that changes to their own notes are appropriate?
Regarding the article I was surprised to see how many therapists had attended a client's social event such as a wedding. This does not at all reflect how our class answered the survey that was provided during the duel relationship discussion. One might imagine that most of the responders in the study were not attending the social events to serve in a therapeutic role.
Having looked over Pope's web sight blogging is beginning to make a lot of sense. As we discuss the dissemination of information, perhaps web site information will be the key to information sharing in EST's ethics etc. What way could possibly be faster in disseminating info?
(p.117 of ethics text)- Mabye I am confused. The text states that a patient can request to have information in their file changed, but only if the psychologist deems the changes to be appropriate. I am assuming the client is asking the psychologist to make changes in the notes that the psychologist created. Do clients have that power and is so doesn't this create conflict? In addition why would a psychologist decide that changes to their own notes are appropriate?
Wednesday, March 10, 2004
Answers to Moon article questions: 1-B, 2-C, 3-A, 4-A, 5-C
In using the WAIS-R mabye we students are lazy, under-trained, etc. However, we are not computers. I do not have a built in metronome allowing me to lisit numbers at exactly one second apart while lowering my tone of voice on the last digit during the Digit span subtest. In addition we need to consider the state of the client during administration. If a client is clearly becoming frustrated and they have clearly reached the limit of their emotional/cognitive/attentional resources, should we give them a full twenty seconds when they have given up? Conversely during a block design task is it not worth while to test limits on occasion, perhaps giving more time to see if a client can complete a design? Cognitive and personality assessment should be considered a craft. Measures such as the WAIS-R are tools for that craft. Our reports are not simply a list of scores.
Mixed thoughts/feelings concerning prescription privledges:
To not accept the findings of science and technology regarding medication is a mistake. Clearly we are entering an era where technology, such as improved brain scanning methods, will allow for the identification of biological mechanisms underlying psychopathology. Does this mean I ought to be figuring out a way to write prescriptions? I dunno. Mabye therapy will be obsolete if in ten years there is a pill for everything. Fine tune your brain with a variety of fun colors. Mabye thats what our culture wants. Mabye therapy is just too hard.
In using the WAIS-R mabye we students are lazy, under-trained, etc. However, we are not computers. I do not have a built in metronome allowing me to lisit numbers at exactly one second apart while lowering my tone of voice on the last digit during the Digit span subtest. In addition we need to consider the state of the client during administration. If a client is clearly becoming frustrated and they have clearly reached the limit of their emotional/cognitive/attentional resources, should we give them a full twenty seconds when they have given up? Conversely during a block design task is it not worth while to test limits on occasion, perhaps giving more time to see if a client can complete a design? Cognitive and personality assessment should be considered a craft. Measures such as the WAIS-R are tools for that craft. Our reports are not simply a list of scores.
Mixed thoughts/feelings concerning prescription privledges:
To not accept the findings of science and technology regarding medication is a mistake. Clearly we are entering an era where technology, such as improved brain scanning methods, will allow for the identification of biological mechanisms underlying psychopathology. Does this mean I ought to be figuring out a way to write prescriptions? I dunno. Mabye therapy will be obsolete if in ten years there is a pill for everything. Fine tune your brain with a variety of fun colors. Mabye thats what our culture wants. Mabye therapy is just too hard.
Wednesday, February 25, 2004
Answers to Pope article questions: 1-D, 2-B, 3-D, 4-A, 5-C (but evidence for A is also on p.149), 6-B, 7-A, 8-B, 9-A, 10-C
The Pope article regarding sexual attraction is concerning. This is specifically due to the number of therapists who responded that they refrained from sexual intimacies with clients for reasons such as being in a relationship, or because the sexual interaction might be damaging to the therapist. I suppose this kind of reasoning is why the issue of boundary crossing with clients is so prevelant. I assumed that the difficulty regarding multiple relationships and boundaries would be focused on more complicated or subtle decisions such as accepting gifts or treating a friend of a friend.
In addition I think that although the language used is psychoanalytic in regards to countertransference (inthis case sexual feelings for a client), the concept is applicable to all therapists from all orientations. Reactions to clients that involve sexual attraction may occur but cannot be acted on at all let alone two years later. Two years appears to be an entirely arbitrary number anyway. Can you go out and have coffee right away? Can you develop intimacy prior to the two year date for coitus?
The Pope article regarding sexual attraction is concerning. This is specifically due to the number of therapists who responded that they refrained from sexual intimacies with clients for reasons such as being in a relationship, or because the sexual interaction might be damaging to the therapist. I suppose this kind of reasoning is why the issue of boundary crossing with clients is so prevelant. I assumed that the difficulty regarding multiple relationships and boundaries would be focused on more complicated or subtle decisions such as accepting gifts or treating a friend of a friend.
In addition I think that although the language used is psychoanalytic in regards to countertransference (inthis case sexual feelings for a client), the concept is applicable to all therapists from all orientations. Reactions to clients that involve sexual attraction may occur but cannot be acted on at all let alone two years later. Two years appears to be an entirely arbitrary number anyway. Can you go out and have coffee right away? Can you develop intimacy prior to the two year date for coitus?
