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Trends & Changes In Ethics And Practice
Of Psychotherapy & Counseling:

Update on Changes and Trends in Professional Codes of Ethics, Professional Guidelines and The Standard Of Care

By Ofer Zur, Ph.D.
 

This article is part of an Online Course for CE Credits on Ethical Decision Making.

To cite this page: Zur, O. (2014). Trends & Changes in Ethics and Practice of Psychotherapy & Counseling. Retrieved month/day/year from http://www.zurinstitute.com/trendsinpsychotherapy.html

 

This page provides a summary and update on some of the general professional issues of our time, reviews specific changes in recent years in the professional codes of ethics, reports on updated guidelines by professional associations and agencies, and reviews some of the general shifts and trends in the practice of psychotherapy and counseling.

This page first reviews the general development in the field in regard to telehealth, HIPAA, confidentiality, record keeping, and risk management. Then it gives more specific updates on issues related to dual relationships, therapeutic boundaries (i.e., self-disclosure, bartering, touch), releasing test data, child custody, parental alienation, repressed memories, treatment of trauma, treatment of Borderline Personality Disordered Patients, psychopharmacology, subpoenas, and additional issues related to modern technologies.

Free resources are provided for each of the topics and additional resources and online courses on the topics are cited.

Subject Areas in Psychotherapy and Counseling that Have Gone Through Some Changes in Recent Years or Merit the Attention of Psychotherapists and Counselors

 

Table Of Contents

California's 2014 Law, AB1775
TeleMental Health And E-Therapy
HIPAA
Confidentiality
Record Keeping
Risk Management
Dual Relationships
Releasing Test-Data
Therapeutic Boundaries (self-disclosure, bartering, touch, etc.)
Child Custody Evaluation
Parental Alienation Syndrome
 

Subpoenas
Repressed Memories
Treatment Of Borderline Personality Disordered Patients
Neuropsychology And Treatment Of Trauma
Psychopharmacology
DSM Update And What Happened To PDM?
Duty To Report, Danger To Others, Tarasoff &Amp; Ewing
ADHD: Fact Or Fiction
Treatments Of Alcoholism And Substance Abuse
Google Factor: What Clients Can Find Out About Their Therapists

 

California's new 2014 law, AB1775:

This law requires psychotherapists to report if a patient has knowingly downloaded, streamed, or even simply accessed (that is, viewed) an electronic or digital image in which anyone under 18 "is engaged in an act of obscene sexual conduct." That's any image that lacks "scientific, literary, artistic, or political" value. More details and critique of this law

 

TeleMental Health, E-Therapy, and E-Mail Communication:

Telemedicine is becoming more prevalent as technological advancement continues to influence how we deliver services and treat our clients. In increasing numbers and frequency our clients are emailing and text messaging us, requesting sessions by phone, and requesting therapy that is exclusively delivered via the Internet. Some of the most cited concerns in regard to e-therapy and email communications are issues of confidentiality, privacy, informing clients about the vulnerability of email and other Web-based communication in regard to privacy so they can make informed consent about treatment, discovering clients' identity, making proper assessment of client suitability for e-therapy, application of reporting laws, and crisis interventions (Zur, 2007a). Some of the most important, however unresolved, issues are practicing across state lines, Skype compatibility with HIPAA, reimbursement, and treating clients in different countries.

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HIPAA

Starting in 2003, Health Insurance Portability and Accountability Act (HIPAA) regulations were introduced and covered areas such as confidentially, electronic storage and transmission, clients' rights in regard to autonomy, privacy, and accessibility to records. These regulations have had an impact on the field in several ways. While HIPAA has not changed the basic ways that psychotherapists are conducting their practices, it has provided new guidelines in regard to several important areas. Many clinicians erroneously believe that if they do not transmit billing electronically, they do not need to be HIPAA compliant. It is the belief of the author of this page and of many, if not most, experts in the field that HIPAA is becoming the standard of care in the fields of medicine and psychotherapy and counseling. HIPAA introduced a few new constructs, such as "Psychotherapy Notes," "Minimum Necessary," and "Need to know" (Zur, 2005). It also asserts that clients have, generally, the right to access their raw test data, a topic that has been legally disputed by test publishers. Another important aspect of HIPAA is that it enables and allows clients extensive access to their medical records and establishes a process whereby clients can request an amendment to their records. Additionally, clients have the right to determine who has access to their records. The interaction between HIPAA law and state law is being handled through what has been called preemption analysis. Similar to APA and other professional organizations, the author of this page highly recommends that all psychotherapists and counselors become HIPAA compliant regardless of whether they transmit electronic billing or not. HIPAA is becoming the standard of care for medicine in general and for the entire mental health delivery system. The early fears about punitive, expensive and fierce enforcement of HIPAA laws by the Department of Health and Human Services had been dissipated by 2006. The Department has taken an educational approach with the aim of informing practitioners and institutions that were reported to misinterpret or ignore HIPAA law. Also, unlike early expectations, there is no "HIPAA Police" and the Department is only responding to consumers' complaints. More recent and ongoing updates

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Confidentiality

Confidentiality regulations and guidelines continue to evolve. It is very important for therapists to be aware of their own state's laws in regard to confidentially as well as their professional associations' codes of ethics and the standard of care within the communities and settings they are practicing. Office Policies and Informed Consent are extremely important when it comes to confidentiality. These forms should include exceptions to confidentiality, such as child abuse mandated reporting and danger to self or others mandated reporting. Tarasoff rulings have been evolving in several ways and therapists must keep themselves abreast of the legal developments in their states. Psychotherapists and counselors should have all clients sign the Office Policies and Informed Consent prior to treatment. The 21st century and the digital age have introduced new complexities regarding confidentiality. These include concerns with social networking, use of Skype, texts, and other digital communications methods.

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Record Keeping

Record keeping guidelines by states and professional organizations have continued to evolve and change over the years. HIPAA regulations have also affected some of the ways that therapists should keep records and introduced a new category of records called "Psychotherapy Notes." Adequate notes generally include relevant history, diagnosis or focus of treatment, goals, therapeutic methods employed, and termination or treatment summary. Emergencies, child abuse and other reporting, crisis interventions, extensive use of touch, or complicated dual relationships should be cited in the records as well. Informed consents, authorizations to release records, e-therapy disclosures, etc. all should be included in the records. The APA 2007 Record Keeping Guidelines (see link below) is one of the most comprehensive guidelines in our profession. Psychotherapists and counselors must follow state laws in regard to record keeping and record retention.

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Risk Management

Risk management, or what has been called defensive medicine, is a very controversial issue in medicine in general as well as in the field of psychotherapy and counseling. Risk management practices started to proliferate in the early 1990s, when it had been introduced into texts, graduate schools, and continuing education workshops. In the field of psychotherapy there have been two competing forces on how to approach risk management: On one side are the conservative-defensive-legalistic forces who advocate that psychotherapists avoid any action that may not "look good" in court or in front of ethics committees, regardless of its clinical efficacy. On the other side are those who believe that client care does not need to be compromised in order to avoid risk, and ethical risk management is possible and preferable (Lazarus & Zur, 2005; Zur, 2007a). The author of this page takes a clear stance that risk management should not compromise the quality of care, and ethical practitioners should not be driven by fear of litigation. He believes that psychotherapists must operate with integrity, protecting both their clients and themselves by using a sound, ethical decision-making process, using consultation when necessary, and keeping good records.

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Dual Relationships

Dual relationships in psychotherapy have been one of the most controversial topics within the realm of ethics. While the old thinking was that dual relationships inevitably lead to exploitation, harm, and sex, since the mid 1990s many ethicists, practitioners, and legislators have realized that dual relationships in small communities are unavoidable, they are mandated in settings such as the military and prisons, and theymay be clinically beneficial in many other situations. Accordingly, some of the major professional associations have changed the ethical codes in regard to dual relationships. For example, the APA's code of 2002 states: "Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical." The ACA's code of ethics of 2005 states: "When a counselor-client nonprofessional interaction with a client or former client may be potentially beneficial to the client or former client, the counselor must document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client." The United States Association for Body Psychotherapy (USABP) Ethical Guidelines of 2007 has also changed its tune from the prior code and states "Body Psychotherapists make a distinction between normally occurring community interactions and multiple relationships ...In some situations, for example in small geographical or modality communities, a multiple relationship that is non-exploitive may be undertaken" (Section V). The faulty beliefs of the depravity of dual relationships and that dual relationships are likely to lead to exploitation, harm, and sex are being put to rest. Increased numbers of prominent publications (i.e., APA Books, ACA, Springer Publishing Co.), well-circulated professional journals (i.e., PPRP, IP), prominent scholars (i.e., Barnet, 2007; Herlihy & Corey, 2006; Knapp & VandeCreek, 2006; Lazarus & Zur, 2002; Schank & Skovholt, 2006; Younggren & Gottlieb, 2004) have all acknowledged that dual relationships are neither always harmful nor always avoidable and can also be beneficial. By 2006 even authors, such as Kenneth Pope (Pope & Wedding, 2008), Janet Sonne (2006), and Melbia Vasquez (2007) have published articles that, in essence, reverse their earlier negative view of dual relationships and clearly acknowledge that they are unavoidable in many situations and communities and neither are always harmful nor inevitably lead to harm or sexual relationships. Without any doubt, the field of psychotherapy and counseling has evolved in recent years to acknowledge the reality and potential clinical benefits of dual relationships. Obviously, dual relationships that are likely to impair the therapist's clinical judgment or that are likely to cause harm or be exploitative must be avoided.

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Releasing Test Data

HIPAA regulations, to the dismay of most publishers of psychological testing and assessment tools, have required therapists to release raw test data to clients upon the client's request. The conflict between federal law and publishers' contracts put practitioners who use psychological testing in a legal and ethical bind. Accordingly, the APA Code of Ethics of 2002 (Standards 9.04 and 9.11) eliminates a prohibition in the 1992 code that prevented psychologists from releasing raw test data to individuals who are not qualified to use them. Now, psychologists and many other psychotherapists must release test data to clients and their designees when clients provide a written release. The changes were made in response to the Health Insurance Portability and Accountability Act (HIPAA), which directs providers to release certain health information to clients upon request. The 2002 code does permit psychologists to withhold test data to protect the client from "substantial harm or misuse or misinterpretation of the data or the test." However, HIPAA does not recognize the misuse or misinterpretation of tests as a legitimate reason to withhold health records. It is highly suggested that practitioners who are facing requests to reveal raw test data should consult with attorneys who are specialized in this area of law before they proceed.

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Therapeutic Boundaries:

Therapeutic boundaries include self-disclosure, touch, bartering, gifts, home visits, etc. As in the case of dual relationships, there has been a distinct shift in the field of psychotherapy and counseling since the mid 1990s toward more flexible and context-based application of boundaries. Unlike the analytic and risk management dominant rules of "Do not touch!" "Never exchange gifts!" "Avoid bartering at all costs!" and "Keep self-disclosure to a minimum!" more and more of the professional literature discusses the importance of flexibility for therapeutic effectiveness. Following are short reviews of the change in professional attitudes towards therapeutic boundaries (for more extensive reviews and updates, see Boundaries in Psychotherapy by the author of this page (Zur, 2007a)):

Bartering: It seems that the new millennium has brought to the fore the realization that bartering is a legitimate way of paying for services in certain cultures and by clients who are cash poor and/or are too proud to accept free therapy (Zur, 2004a). The 2002 APA Code of Ethics deleted the strong cautionary language of the 1992 Code, which stated, "Psychologists ordinarily refrain from accepting goods, services, or other non-monetary remuneration . . ." Similarly, the ACA Code of Ethics of 2005 dropped the 1996 statement, "Bartering Discouraged." Instead it introduces a more reasonable and flexible guideline, which states in section A.10.d. Bartering "Counselors may barter only if the relationship is not exploitive or harmful and does not place the counselor in an unfair advantage, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract." The United States Association for Body Psychotherapy (USABP) Ethical Guidelines of 2007 dropped its 2001 statement of"Body Psychotherapists do not barter (including work exchange) unless the bartering arrangements are appropriate in the context of the therapeutic relationship, indicated by the needs of the client, and for the welfare of the client"(Section V). Several other associations are still lagging behind and use archaic negative terms in regard to bartering.

Self-Disclosure: The 1990s has also been witness to a change in attitude toward self-disclosure. The old analytic and risk management instruction to therapists to limit disclosure to one's name, degree, and fee has been replaced with the realization that clinically appropriate self-disclosure can be highly therapeutic. Texts such as Farber (2006), Schank and Skovholt (2006), or Stricker and Fisher (1990) identify the benefit and importance of appropriate self-disclosure and some, such as Lazarus (1994), Zur (2007a), and others, articulate the harm to therapeutic relationships and to therapy that may result in rigid avoidance of self-disclosure. The attitudes toward self-disclosure have changed so significantly that even the psychodynamic and psychoanalytic literature has started to discuss the value of self-disclosure in the analytic exchange (i.e., Renik, 1996).

Non-Sexual Touch: Touch is one of the most important human experiences, what Montague called "The mother of all senses." Despite half a decade of scientific research that has documented the importance of touch for emotionally and physically healthy development and healing, most forms of touch have been highly sexualized by the culture at large and in the field of psychotherapy. From a risk management point of view, a handshake has been seen as the limit of physical touch. As with other therapeutic boundaries, the 1990s have signified a shift from rigid prohibition toward context-based interventions. Toward the end of the 20th century we witnessed the reemergence of body psychotherapeutic disciplines, including the United States Association of Body Psychotherapists and its Journal and the increased research and publication on the efficacy of touch in the treatment of trauma (i.e., Hunter & Struve, 1998; Smith, Clance, & Imes, 1998). Illustrative of the changing times are the article by Dr. Koocher, APA Past President, in the APA Monitor, in which he touchingly describes holding the hand for a long time of a young woman who had cystic fibrosis with severe pulmonary disease (Koocher, 2006). Even some psychodynamic- and psychoanalytic-oriented psychotherapists have crossed the threshold and discussed the effectiveness of touch in analysis (Fosshage, 2000).

Adventure Therapy: Adventure therapy, or what has also been called outdoor therapy, has imploded since the early 1990s with the proliferation of drug rehabilitation, inpatient programs, and remotely located alternative boarding high schools, resulting in a prodigious upsurge in the practice of outdoor or adventure therapy. This therapeutic approach is obviously implemented outside the traditional office space and is also known as wilderness therapy, camping therapy, outdoor pursuits, and risk education (Zur, 2007). What unifies these programs is that they are conducted in the outdoors, where clients are physically and emotionally challenged to overcome their fears and reassess their self-perceptions. They examine their beliefs in both their limitations and their abilities and learn to rely on themselves and the group to carry out a variety of assigned tasks.

Out-Of-Office Experiences: Even though using behavioral therapy for phobia has always alluded that in-vivo desensitization may take place outside the office, and family therapy has considered "anorexic lunch" as a legitimate intervention, it was not until the mid 1990s that this issue came to the forefront of the profession. Lazarus discusses these ideas in his 1994 paper and Zur (2001) expounded on the topic in a paper titled "Out-of-office experience: When crossing office boundaries and engaging in dual relationships are clinically beneficial and ethically sound." These out-of-office experiences include home visits, flying with a client who suffers from fear of flying, attending clients' weddings, confirmations or Bar Mitzvahs, attending a client's gallery opening, etc. The 2005 ACA Code of Ethics makes special mention of out-of-office experiences when it states: "Examples of potentially beneficial interactions include, but are not limited to, attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service or product provided by a client or former client (excepting unrestricted bartering); hospital visits to an ill family member; mutual membership in a professional association, organization, or community."

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Child Custody Evaluation:

There are several issues that psychotherapists should pay attention to in regard to child custody evaluations. These issues involve the high number of licensing board complaints by the party that did not get what it wished for, concern with the scientific validity of the psychological assessment of parental fitness, and issues concerning claims of Parental Alienation Syndrome. The last concern is addressed in the next section. The most reported complaints to licensing boards at the beginning of the 21st century have been against psychologists who conducted child custody evaluations for the courts. This high frequency of complaints has replaced earlier years' complaints that surrounded issues of multiple personality, repressed memory, and sexual misconduct. Child custody cases that are litigated in family courts around the country are almost always highly contentious and often volatile. Frequently, at least one of the parties involved in such cases is displeased about the outcome of the custody evaluation and the outcome of the court's decision regarding custody of children. The dissatisfied parent in a Family Court case often resorts to filing a complaint with the licensing board against the evaluating psychologist. An added complexity to the issue of child custody evaluation is the fact that several scholars do not believe that psychology has any valid and reliable tools to assess child custody issues and parental competence. They claim that psychological tests, such as the MMPI and the Rorschach tests, parent-child relationships inventories, and clinical interviews and observations do not have any scientifically proven predictive power when it comes to custody decisions. This argument is tied to the more general view of psychology as lacking the basic scientific base of objective assessment (i.e., no blood tests, X-Rays or MRIs that detect mental illness). The related issue of Parental Alienation Syndrome is reviewed in the next section. Regardless, it is very important that psychologists or any other psychotherapists who conduct custody evaluation should be well trained, comply with states', counties' or courts' specific training requirements, certifications or specializations and conduct the evaluation according to the standard of care adopted by the courts. The evaluating psychologist must follow the Code of Conduct and Ethical Principles and the Guidelines for Child Custody Evaluations in Divorce Proceedings established by the American Psychological Association (APA). These guidelines establish the standard of care for the practice of psychology.

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Parental Alienation Syndrome

One of the most heatedly debated topics of the early years of the new millennium is the phenomenon Dr. Gardner dubbed Parental Alienation Syndrome, known as PAS. PAS describes divorce scenarios in which the child becomes aligned with one parent and obsessed with unjustified deprecations of the other parent. The aligned parent is seen as all good, while the alienated parent is seen as all bad. One side of the debate is that of those who view PAS as an important social problem that puts children at risk for losing a once-loved parent unnecessarily and for developing psychological problems as they grow older. The other side of the debate is of those who view PAS as a cover for conspiracy against women's parental rights to raise their children. Those who are against PAS view it as often supported by abusive, vindictive and predatory men-husbands. PAS research also focuses on false allegations of abuse by parents. It is very important that clinicians who suspect they have a PAS case under their care get information and education on this volatile subject before they proceed with assessment, treatment, or any form of reporting.

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Subpoenas

Sooner or later in their careers, most psychotherapists and counselors are likely to receive a subpoena requesting client records. Therapists often react with dread and with a fight or flight response when served with a subpoena, which can result in either ignoring the subpoena or immediately providing the requested records. Either response may be illegal, unethical, and counter-clinical. Responding to subpoenas can be complicated and complex, since legal requirements sometimes conflict with ethical guidelines and copyright laws. A subpoena is a legal document or order requiring an individual (psychotherapist) to appear, and usually to testify, in court on a certain date and/or to produce documents. Subpoena duces tecum is derived from the Latin meaning "bring it with you." It is an order requiring a witness (psychotherapist) to bring specific documents, reports, tapes or any other specified records that are in the possession or under the control of the witness to a certain place at a certain time. A neutral person who is not party to the litigation serves a subpoena, usually, a professional, a sheriff, or someone else who delivers a copy in person or leaves it at the intended recipient's residence or place of business. Attempting to avoid being served a subpoena is most likely unrealistic. It is very important to understand the differences between the various types of subpoenas, especially between a subpoena initiated by an attorney vs. a court-ordered subpoena. In contrast to subpoenas generated by attorneys, a subpoena generated by a court is considered a court order and is generally issued only after a hearing before a judge. Such a court order is likely to compel a disclosure, unless the order is appealed to a higher court or the court/judge changes its opinion at the request of the therapist, the client, the attorney, or other parties. In the end the court must decide what information or records are protected and what are not. One of the simplest and most overlooked ways to handle subpoenas is to seek the client's permission to release the requested information to the entity cited in the subpoena. There are many clinical, ethical and legal factors that therapists must take into consideration before they determine how to respond to a subpoena. Some guidelines are provided below.

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Repressed Memories

In the late 1980s and early 1990s the number of, primarily, woman claiming they had been sexually abused, satanically tortured, or brutally mistreated had exploded. Similarly and concurrently, young children's accounts of sexual abuse had also been on the rise. Families have fallen apart as primarily adult women have accused their parents of inflicting sexual and other assaults upon them as children. The general population, legal justice system, and profession of psychology appear to be divided on the believability, validity, and accuracy of these memories, many of which surfaced in the context of individual or group psychotherapy as much as several decades after the alleged actions took place. Similarly, the public has been divided about the validity of young children's testimonies. The nature of memory is at the heart of the debate. The debate is whether memories are fixed like concrete or are malleable like mud and has been closely tied to issues of gender politics. One side of the debate is represented by Dr. Loftus, who authored the famous study of implanted memories, "Lost in the Mall," in her 1993 paper, "The Reality of Repressed Memories," and the False Memory Foundation (FMF). The other side of the debate is represented, among others, by Dr. Jennifer Freyd, Dr. Kenneth Pope, and Dr. Hopper. The number of lawsuits based on repressed memories had reached its peak in the late 1990s and almost disappeared completely by the turn of the century. This is primarily due to the efforts of Dr. Loftus and the FMF, who helped parents to successfully sue therapists who were accused of implanting false memories. A recent extensive study by Geraerts et al. (Psychological Science, 18 (7), 564568) came to a conclusion that takes a middle ground between the two opposing positions:

"Continuous of childhood sexual (CSA) abuse memories and discontinuous memories that were unexpectedly recalled outside therapy were more likely to be corroborated than anticipated discontinuous memories recovered in therapy. Evidence that suggestion during therapy possibly mediates these differences comes from the additional finding that individuals who recalled the memories outside therapy were markedly more surprised at the existence of their memories than were individuals who initially recalled the memories in therapy. These results indicate that discontinuous CSA memories spontaneously retrieved outside of therapy may be accurate, while implicating expectations arising from suggestions during therapy in producing false CSA memories."

Therapists who are confronted with repressed memory situations must be very careful, as such situations can be clinically and legally volatile. They are advised to follow professional guidelines (see below) for handling such situations, refer if these areas do not fall within their scope of practice, and consult with expert clinicians and attorneys when necessary

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Treatment Of Borderline Personality Disordered Patients

The treatment of Borderline Personality Disorder (BPD) has gone through many trials and tribulations. This pervasive pattern of instability of interpersonal relationships, self-image, and affect that characterizes this disorder has caused a lot of anguish to psychotherapists and counselors who have tried to treat the disorder. The impulsive and volatile nature of these clients and the chronic nature of the disorder have resulted in low levels of treatment efficacy. People with BPD often are highly sensitive to what they view as rejection or abandonment and very often react to perceived or real rejection with intense rage and, at times, vindictiveness. The feeling of rejection or abandonment can arise from minor occurrences, such as when a therapist is late by a few minutes or when a therapist cancels a session because of illness or a scheduled vacation. Their interpersonal relationships, by definition, are unstable and volatile and their perceptions of relationships seem to be shifting and extreme, as they often oscillate between black and white perceptions of the other and the relationship. As a result of the their volatile, rageful and, at times, vindictive nature, people with BPD are represented in high percentages in complaints filed against psychotherapists with licensing boards and in courts in malpractice suits. As these clients often feel wronged and victimized, they tend to exaggerate, distort, fabricate, embellish, lash out with anger and rage, and seek revenge. Part of the complication is that individuals suffering from BPD often have been sexually molested at a young age and are at greatest risk for therapist-patient sexual involvement. To complicate matters even more, individuals who suffer from borderline or histrionic disorders tend, at any given time, to manifest symptoms that greatly resemble those of the so-called "Therapist-Patient Sex Syndrome." It is close to impossible to create causal relationships between the sexual relationship and the symptoms with these clients or simply tp verify the allegation, because these clients are likely to manifest the symptoms on the checklist regardless of whether they had experienced sex with a therapist or not. Setting clinically appropriate boundaries with BPD clients and practicing risk management with these clients is very important. Therefore, sessions, boundary setting, emergencies, and crisis interventions should be documented. Consultation with medicating physicians and other professionals should also be documented. Because the BPD clients often distort reality, therapists' records are very important.

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Neuropsychology And Treatment Of Trauma:

The treatment of trauma has significantly advanced since the early 1990s and continues into the beginning of the 21st century. Driven by advances in technology and brain and neuroscience research, the fields of neuropsychology and trauma research have dramatically progressed. Some of the more prominent resources in the field have been developed by Dr. Daniel Siegel (1999), who has created a new field of Interpersonal Neurobiology; Dr. Alan Schore (1994), who like Dr. Siegel focuses on affect regulation and the neurobiology of emotions; Dr. Bessel A. van der Kolk (1994), who has been studying the biological response to trauma and treatment of PTSD; Dr. Peter A. Levine (Levine & Frederick, 1997), who developed the Somatic Experience (SE) modality in the treatment of trauma, utilizing built-in, natural, or innate immunity to trauma that enables a patient to return to normal in the aftermath of highly "charged" life-threatening experiences; Babette Rothschild (2002), who developed Somatic Trauma Therapy a physiologically based methodology for treatment of trauma; And Shawn Bush (Bush & Drexler, 2002), who focuses on the application of neuropsychology to the geriatric population.

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Psychopharmacology

A number of new developments took place toward the end of the 20th century and at the beginning of the 21st century in regard to biological treatment of mental illness.

Advertisement of Drugs on TV: One development has been that for the first time the FDA has allowed direct marketing of prescription drugs. Consistent with the baby boomers' view of themselves as informed consumers, information about drugs is delivered during the evening news as well as on the Internet. From Viagra to antidepressants to minor tranquilizers, TV viewers are privy to a barrage of commercials that promise to fix their anxiety, depression, restlessness, and anything else that burdens them.

Black Box Warning: A second development has been that the FDA has developed a warning system (called black box warning or sometimes called a black label warning), which is a type of warning that appears on prescription drugs that may cause serious adverse effects. It is so named for the black border that usually surrounds the text of the warning. A black box warning means that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. Black box warnings on drugs received increased media attention in the United States in 2005. Among some of the more widely covered stories are that the FDA has required black box warnings to be placed on all antidepressant medications, warning that they may result in increased risk of suicidal tendencies in children and adolescents. In 2006 the FDA voted to include black box warnings on methylphenidate formulationsused to treat ADHD because of possible cardiovascular side effects. (A month later the agency's Pediatric Advisory Committee effectively rejected recommending boxed warnings for both cardiovascular and psychiatric adverse effects.)

Prescriptive Authority to Psychologists: A third development is the professional, legal, and legislative effort to allow psychologists prescriptive authority for psychotropic drugs. The effort, opposed strongly by psychiatrists, has been successful. Four psychologists have completed the training and have full prescription privileges. So far several states, such as New Mexico, the territory of Guam, and Indiana, have passed laws allowing trained psychologists to prescribe. Many other states have introduced legislation regarding prescription privileges for psychologists.

Increased Awareness of Abuse, Side Effects and Risks Associated with the Use of Psychotropic Medications: A fourth development is the increased awareness of the economic forces that fuel the psychopharmacology approach and the potential damage that these medications can cause. While Dr. Thomas Szasz (i.e., Pharmacaracy: Medicine and Politics in America, Myth of Mental Illness) has been around for a few decades, more recently, Dr. Peter Breggin (Toxic Psychiatry) has focused on exposing how antidepressants can increase the risk of suicide and violent behavior (i.e., The Spellbinding Effect of Psychiatric Drugs - How Antidepressants and other psychiatric drugs cause mayhem, murder, and suicide) and potential extensive and long-lasting damage that can be caused by ADHD medication (i.e., The Ritalin Fact Book: What Your Doctor Won't Tell You About ADHD and Stimulant Drugs.)

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DSM Update, and What Happened to the PDM?

DSM: While the traditional use of the DSM for insurance purposes has not changed much in the past four decades, more critical reports have appeared in the professional literature. Most of the criticism is focused on the concerns that the DSM lacks validity and reliability, does not have scientific foundation, and is driven by politics rather than by science, decisions are made by lobbying and votes rather than by scientific conclusions, it tends to pathologize women and minorities, and most importantly, it focuses on individual diagnosis that serves the pharmacological industry and largely ignores social issues of racism, homophobia and sexism, and existential considerations (Caplan, 1995; Caplan & Cosgrove, 2004; Kirk & Kutchin, 1992; Kutchins & Kirk, 1997; Szasz, 2001). The DSM-5 was published in 2013 and is going to be as financially successful for the American Psychiatric Association as all the earlier versions.

PDM: The Psychodynamic Diagnostic Manual (PDM) was developed by the most prominent psychoanalytic associations worldwide. After many years it was finally published in 2005. Developed by a Task Force selected by the presidents of the five major psychoanalytic organizations, the PDM covers adults, children and adolescents, and infants, emphasizing individual variations as well as commonalities. In focusing on the full range of mental functioning, the PDM complements the DSM's and ICD's efforts in cataloguing symptoms. It systematically describes: (1) healthy and disordered personality functioning; (2) individual profiles of mental functioning, including patterns of relating, comprehending, and expressing feelings, coping with stress and anxiety, observing one's own emotions and behaviors, and forming moral judgments; (3) symptom patterns, including differences in each individual's personal or subjective experience of his or her symptoms. In an odd way after big expectations brought up by major professional and popular newsletters and magazines, the PDM seems to have disappeared off the professional screen.

DSM

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Danger to Others, Duty to Report, Tarasoff, and Ewing:

Originally, California Civil Code 43.92 clarified the Tarasoff Statute and states, with regard to the duty to warn, "where the patient has communicated to the psychotherapist a serious threat of physical violence against a reasonably identifiable victim or victims." In these situations the psychotherapist's duty is to make a "reasonable effort to communicate the threat to the victim or victims and to a law enforcement agency." Failure to act may also result in potential civil liabilities. In July 2004 a California court extended the Tarasoff Mandated Reporting Standard. Ewing v. Goldstein is a California appeals court decision that extended the interpretation of the Tarasoff warning law. The court expanded the definition of Civil Code 43.92 to "include family members as persons covered within the statute who, upon communication to a therapist of a serious threat of physical violence against a reasonably identifiable victim, would trigger a duty to warn." The court states in Goldstein: "The intent of the statute is clear. A therapist has a duty to warn if, and only if, the threat which the therapist has learned whether from the patient or a family member actually leads him or her to believe the patient poses a risk of grave bodily injury to another person." The expanded duty from now on applies to credible threats received from the patient, or the patient's family; however, the court made clear that its decision did not go beyond "family members." The court decision has several meanings. At the most basic level it means that therapists in California could be held liable for failure to issue a Tarasoff warning when the information regarding the dangerousness of one of their clients comes from a patient's family member rather than the client. Many experts are deeply concerned with the potential for further deterioration of psychotherapy privacy as a result of the decision. Others are concerned that the decision will be misused in family, custody and other disputes, the way child abuse reporting has been misused. Yet other experts view the alarmed responses as exaggerated and believe that the impact of the decision is rather limited. They view the decision as merely implying that therapists cannot ignore third party statements about dangerousness and do not view it as a major change from how therapists have already been practicing. They take the position that, as before, therapists must integrate any statements about dangerousness, regardless of their source, into the clinical-ethical-legal decision-making. Undoubtedly, it will take time and further court rulings before the dust settles on this issue. However, the new court decision may have further significant implications for therapists as it leaves open extremely important questions, such as who is considered to be a family member? How does one verify that the person who communicates to the therapist is who he says he is? What about a credible third party report of threat? How does the communication take place: email, fax, and phone call? How is the potential victim identified? At this time, these and many other questions remain unanswered for the most part. When confronted with a Tarasoff situation, consult with a legal expert and document your clinical-ethical-legal decision-making in detail.

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ADHD: Fact Or Fiction

The debate about the merit of the ADHD diagnosis and the economic and other forces that drive its popularity has been intensifying since the beginning of the 21st century. During this period an increased number of children have been diagnosed with ADHD and new Adult ADHD designations have been assigned to the adult population. During this period we have witnessed children as young as two years old and adults as old as eighty being diagnosed with ADHD. On one side of the debate are those who point to a significant body of research that supports a genetic link for ADHD and positive response to both behavioral and pharmacological interventions. Many parents, therapists who specialized in ADHD, and, of course, teachers and school administrators and the psychopharmacological industry are also on this side of the debate. On the other side are those who argue that ADHD, as a diagnosis, is nothing more than a fad that supports poor behavior in those with the diagnosis, takes the focus of parents, helps teachers with classroom control and, most importantly, the pharmacological industry, which makes a huge profit from this popularity of the ADHD diagnosis.

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  • In support of the ADHD DX is CHADD

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Treatments of Alcoholism and Substance Abuse: Abstinence, Harm Reduction, and Control Use:

The debate about ways to treat alcohol and drug abuse has intensified in the past couple of decades. The Alcoholics Aanonymous model of abstinence has been challenged by two other models.

Harm Reduction: Harm reduction is a public health philosophy that seeks to lessen the dangers that drug abuse and our drug policies cause to society. It is a philosophy of public health intended to be a progressive alternative to the prohibition of certain potentially dangerous lifestyle choices. A basic tenet of harm reduction is that there has never been, is not now, and never will be a drug-free society. This strategy seeks pragmatic solutions to the harms that drugs and drug policies cause. Harm reduction may not be very 'nice' or appealing, but its advocates claim that it works. This approach admits that there is no one ultimate or ideal solution to the problem of drugs in a free society. It also looks at issues of individual rights. The harm reduction strategy demands new outcome measurements and acknowledges that current treatment and/or incarceration approaches do not seem to be effective.

Control Drinking: This approach is somewhat similar to the above mentioned Harm Reduction approach. It rejects the ideal of abstinence and takes a more realistic approach of people controlling the amount and how they drink rather than avoiding it all together. The approach rejects the idea that people are helpless and that alcoholism is a disease. It asks people to track their use, take steps to reduce use, conduct cost-benefit analysis, and make a clear plan of how much they drink and, if necessary, when and where.

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Google Factor: What Clients Can Find Out About Their Therapists With A Click Of A Mouse

Psychotherapists are accustomed to looking at self-disclosure as something they intentionally reveal to their clients. However, Internet search engines, such as Google, and specialized for-fee background checks have completely changed the kinds of information clients can obtain about us, their therapists. In the past intrusive clients were known to have searched and found their therapist's home address or marital status or deliberately, or criminally, stalked their therapist. The meaning of stalking has radically expanded with the introduction of Internet Search Engines, such as Google, and thousands of for-fee services that would find almost anything a client might desire to know about their therapist. Clients can find out all sorts of information about their therapist, from home address and marital status to criminal records and tax information. Additionally, with the click of a mouse clients can join online social networks, such as Facebook.com, and "friend" the therapist under a screen name. Then the clients can gain access to all sorts of information, including relationship status, religious views, hobbies, and even favorite songs. Clients can also join professional listservs and chatrooms with rather simple pseudo-names. Often no one checks. Then they may find out how their therapist discusses other clients or even how they are being viewed or discussed by their therapist. Clients who join such listservs may detect information regarding their therapist illegally or unethically committing insurance fraud, charging high co-pays, etc. There are several levels that clients may search for information about their therapist:

  • Clients' curiosity about their therapists when they Google them or check their therapist's professional Web site. This search may yield professional orientation of therapist, training, etc.
  • Clients who are more seriously looking for information about their therapists. This "due diligence" or thorough approach may include searching the licensing board's Web site to see if their potential therapist had any complaints filed against him or her.
  • Clients may "push the envelope" and intrusively search for information about their therapists. They may search for home address or to identify marital status or family members, etc. This may also include disguising one's identity and joining social networks, listservs, etc., in order to find information about therapists or paying for an online service that legally gathers information about the therapist that is not readily available online. This may include divorce or other court records that are considered public records.
  • Clients may hire online services that illegally gather information about the therapist. Such information may include cell phone records and tax records.

Therapists must assume that their clients may read everything they post online. If therapists find out that clients or potential clients have acted in an intrusive manner in regard to online searching, they should think about the clinical, ethical, and legal ramifications, document their concern, respond appropriately and, if necessary, refuse to see clients, terminate treatment, and/or seek consultation. Most important, therapists should Google themselves periodically so they are aware of what their clients may be privy to and learn about ways that they can remove information if they choose to.

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References:

American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author. http://www.counseling.org/Resources/aca-code-of-ethics.pdf.

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 10601073. Retrieved from http://www.apa.org/ethics/code/principles.pdf.

Barnett, J. E. (2007). Boundary Issues and Multiple Relationships: Fantasy and Reality. Professional Psychology: Research and Practice, 38 (4), 401-405.

Bridges, N. A. (2001). Therapist's self-disclosure: Expanding the comfort zone. Psychotherapy, 38, 2130.

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Caplan, P. J. (1995). They say you're crazy: How the world's most powerful psychiatrists decide who's normal. Reading, MA: Addison Wesley.

Caplan, P. J. and Cosgrove, L. (Eds) (2004). Bias in Psychiatric Diagnosis. New York: Jason Aronson.

Farber, B. (2006). Self-disclosure in psychotherapy.NY: Guilford Press.

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Zur, O. (2004a). A chicken for a session: Bartering in therapy. Voices, 40 (1), 7580.

Zur, O. (2004b). To cross or not to cross: Do boundaries in therapy protect or harm? The Psychotherapy Bulletin, 39 (3), 2732.

Zur, O. (2005). HIPAA compliance kit (3rd ed.). Sonoma, CA: OZ Books.

Zur, O. (2007a). Boundaries in Psychotherapy: Ethical and Clinical Explorations. Washington, DC: American Psychological Association.

Zur, O. (2007b). Touch In Therapy and The Standard of Care in Psychotherapy and Counseling: Bringing Clarity to Illusive Relationships. United States Association of Body Psychotherapists Journal (USABP Journal), Fall/07

Zur, O. (2007c). The Google Factor: Therapists' Self-Disclosure In The Age Of The Internet: Discover what your clients can find out about you with a click of the mouse. The Independent Practitioner, (Winter/07).

 
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