Legal and ethical considerations among individual, family, and group modalities of therapy
Domestic violence & sexual abuse:
• Most states require prof... [Show More] essionals to report any suspicion of child abuse.
• Although reporting suspected abuse can jeopardize a therapeutic alliance, sometimes
therapy needs to take a second place to the interests of safety.
• If a clinician does not report suspected child abuse, they should consider the
consequences of making a mistake.
• Perpetrators and victims of childhood sexual abuse don’t usually volunteer this
information.
• Detection of this abuse is up to the therapist who may have to rely on indirect clues
• A child MAY show the following symptoms if they are being abused: sleep disturbance,
encopresis or enuresis, abdominal pain, exaggerated startle response, appetite
disturbance, sudden unexplained changes in behavior, overly sexualized behavior,
regressive behavior, suicidal thoughts or running away.
Ethical Dimension:
• Therapy should be for the client’s benefit, not to work out unresolved issues for the
therapist
• Clients are entitled to confidentiality, but limits of privacy must be imposed in regards to
probation officers, parents, and managed care companies
• Therapists should avoid exploiting the trust of their clients (and students) and must avoid
dual relationships
• Professional are obligated to provide the best possible treatment, if they are not qualified,
they should refer the patient to someone else who is.
• When in doubt regarding ethical issues, its best practice to consult with a colleague or
supervisor.
• Psychologists offer services only within the areas of their competence, based on
education, training, supervision or professional experience.
• When psychologists become aware of personal problems that might interfere with their
professional duties, they take appropriate measures, such as obtaining professional
assistance and determining whether they should limit, suspend or terminate their workrelated duties.
• Social workers should not engage in dual relationships with clients or former clients.
• Social workers should not solicit private information from clients unless it is essential to
providing services
• Social workers should not disclose confidential information to third party payers unless
clients have authorized such disclosure.
• Social workers should terminate services to clients when such services are no longer
required.
• Counselors are not allowed to maintain a relationship with current clients through social
media
• Counselors must wait 5 years after the last clinical contact to have sexual or romantic
relationship with a former client or family member of a client. This applies to both inperson and electronic interactions.
• The APA specifies that when a psychologist provides serves to several people in a
relationship (spouse or parents and children), they must clarify at the start which
individuals are clients and what relationship he or she will have with each one.
• Additionally, if the psychologist is called on to perform potentially conflicting roles (such
as family therapist and witness for one party in divorce proceedings), he or she must
attempt to clarify and change or withdraw from the roles as appropriate.
• The NASW states that when a social worker provides services to a co ule or family
members, he/she should clarify with all parties what professional obligations he or she
has to the various individuals receiving services.
• Also, the social worker should ask all parties to agree to each individual’s right to
confidentiality.
• As a therapist one way to resolve ambiguous ethical dilemmas is to use your own best
judgement.
• When in doubt, clinicians should ask themselves two questions:
1) What would happen if the client or or important others found out about my
actions?
2) Can you talk to someone you respect about what you’re doing (or
considering)?
• The following are “red flags” which should signal potential unethical practices:
1) Specialness - believing that something about the situation is special and that the
ordinary rules don’t apply.
2) Attraction - feeling intense attraction of any kind not only romantic but also being
impressed with the status of the client.
3) Alteration in the therapeutic frame - having longer or more frequent sessions,
engaging in excessive self-disclosure, being unable to say no to the client, and other
things that signal a potential violation of professional boundaries
4) Violating client norms - not referring someone in a trouble marriage for couples
therapy, accepting personal counseling from a supervisor and so on.
5) Professional isolation - not being willing to discuss your decision with professional
colleagues.
COGNITIVE BEHAVIORAL THERAPY
o “A collaborative process of empirical investigation, reality testing, and problem solving
between the therapist and the patient.”
o The basic premise is that depression is the result of cognitive distortions, and these
distortions are learned errors in thinking (Beck)
o CBT is “a system of psychotherapy based on a theory which maintains that how an
individual structures his or her experiences largely determines how he orshe feels or
behaves.”
o Dysfunctional thoughtsrelating to self, world, and/or others are rooted in irrational or
illogical assumptions. The individuals view of self and the world is central to the
determination of emotions and behaviors and thus by changing one’s thoughts,
emotions, and behaviors can also be changed.
o Primary and secondary thinking. Secondary thinking views the social and cultural world
in determinate, positive, rational terms. Primary thinking recognizes the indeterminate,
negative, and irrational as a part of human action forever.
o Clinicalstrategies are used to help the individual recognize the dysfunctional nature of
their thinking patterns and to help the individual change their conclusions.
o Cognitive therapy advocates guided discovery rather than directly challenging the
patient’s views. Allowing the patient to find the answers to their problems as much as
possible.
Socratic Dialogue
o “Mutual discovery in which the therapist guides the patient through a series of
questions and answers to elicit automatic assumptions and examine the logic and
evidence that relates to them.”
o Involves the therapist asking specific questions derived primarily from restatement of
the individual’s own words as the major technique leading the individual to self-discover
insight leading to subsequent changes. https://www.youtube.com/watch?v=hsm6qJUwfM
o 7 types of questions for SD: exampleslocated on p316 in book. History, memory,
translation, interpretation, application, analysis, and evaluation questions.
o Basic Rules to SD located on page 317 in book.
o Labeling of Distortions- patients are helped to identify “dysfunctional or irrational”
thoughts as a type of self-monitoring for more accurate descriptive
o Questioning the Evidence- this technique assists the individual in questioning the facts
related to their cognitions and conclusions. It investigates whether their information is
based on facts or assumptions.
o Examining Options and Alternatives- this technique involves the development of all
possible alternative explanationsto learn the skillsin generating options rather than
“only one way” thinking.
o Reattribution- in individuals with the habit of accepting all or most of the blame for
outcomes, this is an excellent technique for redistribution of responsibility. Thisis also
helpful for individuals with personality disorders that place the blame squarely on the
shoulders of others for most outcomes
o Decatastrophizing- catastrophic thinking is one of the hallmarks of anxious individuals.
These individuals tend to focus on the most negative possible outcome of any given
situation. Decatastrophizing allowsfor balance and realistic focusing by examining the
“worst possible outcome” and developing a plan of action.
o Advantages and Disadvantages- for individuals who appear to be stuck between two
options, examination of the advantages and disadvantages of certain situations helps
them to develop alternative perspectives. This breaks the “all or nothing” mindset and
permits a more balanced view of the situation.
o Paradox or Exaggeration- this technique should only be used by the very skilled
therapist; otherwise, the patient may view this technique as sarcasm or belittling. When
used appropriately, the therapist takes an issue to the extreme to help the person see
the absurdity of their sometimes-overinflated viewpoints.
o Turning adversity to advantage- making lemonade out of lemons. The individual is
helped to identify how to use what appears to be a negative situation to his or her
advantage.
o Cognitive rehearsal- prior to making a behavioral change, it is sometimes less
threatening to “practice” the new behavior through visualization and discussion.
o Automatic thought records- patients are asked to complete columns, identifying a
troubling situation, resulting emotion, and thoughts associated with both. The therapist
and patient work on clarification and development of “rational” responses to debate or
challenge the original reaction.
o Thought stopping- the patient interrupts his or her stream of thought with a sudden
stimulus such as snapping a rubber band on the wrist,saying “stop it” out loud orsome
other real or imagined stimulus and then changes his or her stream of thought.
o Cognitive restructuring- use of an automatic thought record combined with other
cognitive techniquesto effect changesin negative thinking patterns. Table 8.5 in book on
page 321. Tune in…keep a thought diary. Focus on the words that are unhealthy. Stop
the messages. Change the negative to positive.
Behavioral Techniques
o Assertiveness Training- prior to beginning the therapist needs to define the terms
“assertive, aggressive, and passive.” Some individuals don’t perceive their behavior as
aggressive and therefore educating the individual isimportant in modifying the behavior.
o Behavioral RehearsalCh 1
Theorists:
Elaine Miller-Karas says that one’s resilient zone (RZ) is an internal state of adaptability and
"flexibility that is regulated by our nervous system. We feel at our best and can think clearly and
deal effectively with life when we are in our RZ. She states that there is a natural biological
rhythm of the autonomic nervous system between the sympathetic nervous system and the
parasympathetic nervous system, and this corresponds to the RZ. The RZ is also referred to as
the window of tolerance.
Understanding, assessing, and managing anxiety is a cornerstone of Peplau’sInterpersonal
Relations Model for Nursing (1991).
adaptive information processing (AIP) model, developed by Shapiro as an explanatory theory
for EMDR, is a metamodel for understanding mental health and psychopathology, and provides
direction for planning therapeutic interventions
Spielberger Trait Anxiety Scale; 22 on the Beck Depression Inventory, and a 27 on Dissociative
Experiences Scale
Psychotherapy interventions can be designed to target any or all areas of the dissociated
memory or experience—behavior, relationships, beliefs, the body, images, and/or emotions—to
facilitate healing and promote neurophysiological harmony
Luhrmann (cultural anthropologist): Two schools of thought for psychotherapy. 1. The
psychodynamic approach (nature vs. nurture and mental illness attributed to environmental
and psychosocial issues) and the biophysiological model attributes mental illness to chemical
imbalance (i.e., nature). The latter framework attributes mental illness to an imbalance of
neurotransmitters in the brain, and the answer lies in correcting these imbalances, largely
through medication.
Epigenetics: Both genetic vulnerability and environmental influences play significant rolesin the
development of mental illness
Methylation: Methyl groups affix genes that govern the production ofstress hormone receptors in the
brain, and this prevents the brain from regulating the response to stress.
Telomeres, DNA protein structures, have been found to be shortened in the presence of trauma.
Telomere length is associated with the production of destructive radicals and molecules, chronic
inflammation, co-occurring psychiatric disorders, and a shorter life expectancy.
Approximately 70% of adults worldwide experience at least one traumatic event within theirlifetime
25% of all adults have been physically abused as children.
ACE (adverse childhood events) are associated with psychosis and that psychosis would be reduced by
33% if that risk factor were removed
A diagnosis of PTSD plus depression and associated dissociative or borderline personality disorder
appears to be a dose–response predictor for developing a chronic illness such as fibromyalgia, chronic
fatigue syndrome, irritable bowel syndrome, chronic pelvic pain, and dysmenorrhea
Treatment hierarchy framework for practice: Stabilization and Processing
Stabilization (pg 30 APN book) strategies assist the person to be better able to make state changes, that
is, to change one’s present physiology in order to function more effectively in the moment. List of
strategies on pg 30 of APN book
Processing: Processing is based on the idea that humans have an inherent information processing system
that usually integrates experiences to a physiological adaptive state in which information can be taken in,
and learning will occur. Pg 32 in APN book has list of examples.
Both significant traumatic events and adverse experiences affect brain development and structure. [Show Less]
