Current Psychotherapies Chapter 15 Current Issues in Psychotherapy Author: Danny Wedding Instructor: Jeff Garrett Ph.D.

Basic Concepts Human Resource Data U.S. Substance Abuse and Mental Health Services Administration 193,000 Licensed Clinical Social Workers 77,000 Psychologist 41,000 Psychiatrists Regardless of professional discipline and training most therapists practice eclecticism

Human Resource Data

U.S. Substance Abuse and Mental Health Services Administration

193,000 Licensed Clinical Social Workers

77,000 Psychologist

41,000 Psychiatrists

Regardless of professional discipline and training most therapists practice eclecticism

Licensing vs. Certification Licensure – restricts the practice of a profession Certification – restricts the use of a professions name

Licensure – restricts the practice of a profession

Certification – restricts the use of a professions name

Most Frequent Causes for a Loss of License Dual Relationships Unprofessional Conduct Conviction of a Felony Failure to Comply with a Board Order Improper Billing Practices Incompetent Practice

Dual Relationships

Unprofessional Conduct

Conviction of a Felony

Failure to Comply with a Board Order

Improper Billing Practices

Incompetent Practice

AHRQ (Agency for Healthcare Research and Quality) Develops treatment guidelines Proponents suggest process standardizes the quality of care in mental health Critics suggest it leads to a “cookbook” approach negating the uniqueness of cases For more details go to www.guideline.gov

Develops treatment guidelines

Proponents suggest process standardizes the quality of care in mental health

Critics suggest it leads to a “cookbook” approach negating the uniqueness of cases

For more details go to www.guideline.gov

Ethical Issues Dual Relationships When a mental health professional is engaged in multiple types of relationships with the same patient, this is considered an example of a dual relationship Clear that relationships involving sexual or financial involvement violate ethical codes Other types of dual relationships can be more difficult to discern right course of action Adler and Dreikurs suggest therapy is educational and therefore providing therapy to friends and family is acceptable Lazarus and Zur (2002) challenge the rigidity of professional restrictions on non-sexual dual relationships

Dual Relationships

When a mental health professional is engaged in multiple types of relationships with the same patient, this is considered an example of a dual relationship

Clear that relationships involving sexual or financial involvement violate ethical codes

Other types of dual relationships can be more difficult to discern right course of action

Adler and Dreikurs suggest therapy is educational and therefore providing therapy to friends and family is acceptable

Lazarus and Zur (2002) challenge the rigidity of professional restrictions on non-sexual dual relationships

Ethical Issues Sexual attraction Intimacy of psychotherapy can lead to sexual arousal and fantasies 4 out of 5 therapist report feeling sexual attraction to at least one client Most report guilt, anxiety and confusion when sexual feelings occur Only 10% of therapist feel their training prepared them for this type of situation Data regarding the sexual misconduct of therapists suggests incidence rates for sexual misconduct are fairly similar across professional disciplines. “ The guidelines are clear. ... There is no place for sex or other forms of personal intimacy in a professional helping relationship with a vulnerable person.” Edelwich & Brodsky (1991)

Sexual attraction

Intimacy of psychotherapy can lead to sexual arousal and fantasies

4 out of 5 therapist report feeling sexual attraction to at least one client

Most report guilt, anxiety and confusion when sexual feelings occur

Only 10% of therapist feel their training prepared them for this type of situation

Data regarding the sexual misconduct of therapists suggests incidence rates for sexual misconduct are fairly similar across professional disciplines.

“ The guidelines are clear. ... There is no place for sex or other forms of personal intimacy in a professional helping relationship with a vulnerable person.” Edelwich & Brodsky (1991)

Ethical Issues Third-Party Payers Clinicians must be wary of illegal responses to insurance restrictions Legal options include only providing fee for service – (lower rates, offering pro-bono options)

Third-Party Payers

Clinicians must be wary of illegal responses to insurance restrictions

Legal options include only providing fee for service – (lower rates, offering pro-bono options)

Ethical Issues Duty to Warn The legal case of Tarasoff v. the Regents of the University of California pertains to duty to warn Tarasoff I - The legal case of Tarasoff I states that if the patient is at immediate risk of harming someone else, the provider has the duty to warn the intended victim

Duty to Warn

The legal case of Tarasoff v. the Regents of the University of California pertains to duty to warn

Tarasoff I - The legal case of Tarasoff I states that if the patient is at immediate risk of harming someone else, the provider has the duty to warn the intended victim

Ethical Issues Duty to Protect Tarasoff II Hedlund v. Superior Ct. of Orange County States that if a patient is at immediate risk of harming someone else the provider has a duty to take steps to protect the intended victim

Duty to Protect

Tarasoff II

Hedlund v. Superior Ct. of Orange County

States that if a patient is at immediate risk of harming someone else the provider has a duty to take steps to protect the intended victim

Ethical Issues Respondent Supervisor The legal doctrine of respondent superior allows supervisors to be held accountable for the actions of trainees Supervisors may be responsible for tragic outcomes if there is a failure to warn

Respondent Supervisor

The legal doctrine of respondent superior allows supervisors to be held accountable for the actions of trainees

Supervisors may be responsible for tragic outcomes if there is a failure to warn

Ethical Issues Reportable Circumstances Most states have mandatory reporting laws on suspicion of child abuse including Physical abuse Sexual abuse Emotional abuse Neglect

Reportable Circumstances

Most states have mandatory reporting laws on suspicion of child abuse including

Physical abuse

Sexual abuse

Emotional abuse

Neglect

Ethical Issues Privileged Communication Privilege – Special status extended to particular types of communication recognized by the law as unique, important and worthy of protection Extension of the 5th Amendment which gives Right of Privacy Right vested in the client Client can waive

Privileged Communication

Privilege – Special status extended to particular types of communication recognized by the law as unique, important and worthy of protection

Extension of the 5th Amendment which gives Right of Privacy

Right vested in the client

Client can waive

Ethical Issues Prediction of Dangerousness Predicting violence is like predicting the weather – it’s easier in the short term No evidence that therapists predict danger any better than others. In fact, therapist may over predict danger Previous violence is best predictor of future violence - The most powerful predictor of future violence is a history of previous violence Other predictors Head injury Being abused as a child Witnessing a family member abuse others History of psychosis Substance abuse

Prediction of Dangerousness

Predicting violence is like predicting the weather – it’s easier in the short term

No evidence that therapists predict danger any better than others. In fact, therapist may over predict danger

Previous violence is best predictor of future violence - The most powerful predictor of future violence is a history of previous violence

Other predictors

Head injury

Being abused as a child

Witnessing a family member abuse others

History of psychosis

Substance abuse

Ethical Issues Informed Consent Therapist must inform clients of … Nature of treatment Purpose of treatment Risks Benefits Alternative treatments Although it may not be ideal, informed consent can be obtained verbally Except in … Emergencies If consent is waived Incompetent patients

Informed Consent

Therapist must inform clients of …

Nature of treatment

Purpose of treatment

Risks

Benefits

Alternative treatments

Although it may not be ideal, informed consent can be obtained verbally

Except in …

Emergencies

If consent is waived

Incompetent patients

HIPAA Effective April 4, 2003 The Health Insurance Portability and Accountability Act (HIPAA) was developed to protect protected health information Under the Health Insurance Portability and Accountability Act (HIPAA) patient have a right to review and amend their own health records Provides safeguards regarding confidentiality of medical records and medical discussions Allows patients access to their medical records and an avenue for correcting errors in their records.

Effective April 4, 2003

The Health Insurance Portability and Accountability Act (HIPAA) was developed to protect protected health information

Under the Health Insurance Portability and Accountability Act (HIPAA) patient have a right to review and amend their own health records

Provides safeguards regarding confidentiality of medical records and medical discussions

Allows patients access to their medical records and an avenue for correcting errors in their records.

Risk Management Requires The most ethical way to manage risk in psychotherapy listed below is accurate and complete record keeping practices Strict adherence to ethical principles Careful identification of high risk clients Good record keeping standards Willingness to seek consultation as needed Taking patient complaints seriously Practice guidelines such as those developed by the Agency for Health Care Research and Quality will likely be used more frequently to determine appropriateness of care

The most ethical way to manage risk in psychotherapy listed below is accurate and complete record keeping practices

Strict adherence to ethical principles

Careful identification of high risk clients

Good record keeping standards

Willingness to seek consultation as needed

Taking patient complaints seriously

Practice guidelines such as those developed by the Agency for Health Care Research and Quality will likely be used more frequently to determine appropriateness of care

Cross Cultural Issues Ethnic Minorities Cultural differences need to be understood and taken into consideration African-American clients may benefit from action oriented and directive approaches Hispanic clients may benefit from reframing psychological problems in medical terms Filipino Americans may benefit from the therapist adopting a more authoritative style Caution needed to insure individual differences are still focused on regardless of culture Unfortunately some therapist practice in a biased, inadequate, or inappropriate fashion with this patient population

Ethnic Minorities

Cultural differences need to be understood and taken into consideration

African-American clients may benefit from action oriented and directive approaches

Hispanic clients may benefit from reframing psychological problems in medical terms

Filipino Americans may benefit from the therapist adopting a more authoritative style

Caution needed to insure individual differences are still focused on regardless of culture

Unfortunately some therapist practice in a biased, inadequate, or inappropriate fashion with this patient population

Cross Cultural Issues Gay and Lesbian Clients American Psychiatric Association removed homosexuality from its official list of mental disorders in 1973 Almost all therapist will treat gay and lesbian clients 99% of therapists have seen at least one gay or lesbian client 6% of current clients are gay and 7% are lesbian Unfortunately some therapist practice in a biased, inadequate, or inappropriate fashion with this patient population

Gay and Lesbian Clients

American Psychiatric Association removed homosexuality from its official list of mental disorders in 1973

Almost all therapist will treat gay and lesbian clients

99% of therapists have seen at least one gay or lesbian client

6% of current clients are gay and 7% are lesbian

Unfortunately some therapist practice in a biased, inadequate, or inappropriate fashion with this patient population

Psychopharmacology Issues Prescription Privileges for Non-medical Mental Health Professionals Controversial Consumer groups like NAMI have advocated for expansion of prescriptive authority. They argue that it will contain escalating health care cost and increase access to care especially for underserved populations and rural areas Opponents (see Hayes & Heiby, 1998) argue that it … Will blur distinction between psychiatry and other disciplines Potentially endanger the public e.g., failure to recognize risks such as potential drug interactions

Prescription Privileges for Non-medical Mental Health Professionals

Controversial

Consumer groups like NAMI have advocated for expansion of prescriptive authority. They argue that it will contain escalating health care cost and increase access to care especially for underserved populations and rural areas

Opponents (see Hayes & Heiby, 1998) argue that it …

Will blur distinction between psychiatry and other disciplines

Potentially endanger the public e.g., failure to recognize risks such as potential drug interactions

Psychopharmacology Issues Psychopharmacology Curriculums have been proposed In regards to prescription privileges limited practice prescribers would work independently with limited prescriptive authority Producing limited practice prescribers Work independently Consult with physicians when working with difficult cases and problems outside of their typical scope of practice Different from physician extenders who can only work under direct physician supervision

Psychopharmacology Curriculums have been proposed

In regards to prescription privileges limited practice prescribers would work independently with limited prescriptive authority

Producing limited practice prescribers

Work independently

Consult with physicians when working with difficult cases and problems outside of their typical scope of practice

Different from physician extenders who can only work under direct physician supervision

Psychopharmacology Issues Developments to date In the 1990s Department of Defense experiment trains psychologists to prescribe U.S. General Accounting Office (GAO, 1999) investigates project and determined graduates were well trained but expressed concerns about the cost involved in training 1999 Guam passes a bill to grant psychologist prescription privileges 2002 New Mexico first state in the US to allow psychologists prescription privileges 2004 Louisiana also allows psychologists prescription privileges

Developments to date

In the 1990s Department of Defense experiment trains psychologists to prescribe

U.S. General Accounting Office (GAO, 1999) investigates project and determined graduates were well trained but expressed concerns about the cost involved in training

1999 Guam passes a bill to grant psychologist prescription privileges

2002 New Mexico first state in the US to allow psychologists prescription privileges

2004 Louisiana also allows psychologists prescription privileges

The Future of Psychotherapy “ … psychotherapy will become more directive, psycho-educational, present-centered, problem-focused, and briefer in the next decade … self help groups, social workers, and psychiatric nurses will proliferate … integrative, systemic and cognitive persuasions will thrive … specialization and peer review will become vital activities and pharmacotherapy will expand at the expense of psychotherapy.” Norcross, et al. (1992).

“ … psychotherapy will become more directive, psycho-educational, present-centered, problem-focused, and briefer in the next decade … self help groups, social workers, and psychiatric nurses will proliferate … integrative, systemic and cognitive persuasions will thrive … specialization and peer review will become vital activities and pharmacotherapy will expand at the expense of psychotherapy.” Norcross, et al. (1992).

The Future of Psychotherapy Practice guidelines and manual based treatments will be used more frequently Behavioral and cognitive-behavioral approaches will be favored because effectiveness can be measured Increased emphasis on empirically supported treatments Guidelines will be used to decide how and whom third party payers reimburse Technology will become a primary vehicle for health care

Practice guidelines and manual based treatments will be used more frequently

Behavioral and cognitive-behavioral approaches will be favored because effectiveness can be measured

Increased emphasis on empirically supported treatments

Guidelines will be used to decide how and whom third party payers reimburse

Technology will become a primary vehicle for health care

The Future of Psychotherapy Manderscheid & Henderson (2001) HIPPA legislation will allow human rights to be fundamental in the health care system Consumers and family members will be more responsible for their health care Genetic treatments for biologically based disorders will become routine

Manderscheid & Henderson (2001)

HIPPA legislation will allow human rights to be fundamental in the health care system

Consumers and family members will be more responsible for their health care

Genetic treatments for biologically based disorders will become routine

Twenty Things You need to Know About Current Issues in Psychotherapy 1. Estimates suggest the professional discipline with the largest number of members providing clinical services is clinical social work 2. Regardless of professional discipline and training most therapists practice eclecticism 3. Data regarding the sexual misconduct of therapists suggests i ncidence rates for sexual misconduct are fairly similar across professional disciplines

1. Estimates suggest the professional discipline with the largest number of members providing clinical services is clinical social work

2. Regardless of professional discipline and training most therapists practice eclecticism

3. Data regarding the sexual misconduct of therapists suggests i ncidence rates for sexual misconduct are fairly similar across professional disciplines

Twenty Things You need to Know About Current Issues in Psychotherapy 4. Restriction of the practice of a profession involves licensure 5. The legal case of Tarasoff v. the Regents of the University of California pertains to duty to warn 6. The legal doctrine of respondent superior allows supervisors to be held accountable for the actions of trainees

4. Restriction of the practice of a profession involves licensure

5. The legal case of Tarasoff v. the Regents of the University of California pertains to duty to warn

6. The legal doctrine of respondent superior allows supervisors to be held accountable for the actions of trainees

Twenty Things You need to Know About Current Issues in Psychotherapy 7. Privileged communication can only be waived by the client 8. In predicting violence, therapists may overpredict 9. The most powerful predictor of future violence is a history of previous violence

7. Privileged communication can only be waived by the client

8. In predicting violence, therapists may overpredict

9. The most powerful predictor of future violence is a history of previous violence

Twenty Things You need to Know About Current Issues in Psychotherapy 10. Although it may not be ideal, informed consent can be obtained verbally 11. In regards to prescription privileges limited practice prescribers would work independently with limited prescriptive authority 12. The Health Insurance Portability and Accountability Act (HIPAA) was developed to protect protected health information

10. Although it may not be ideal, informed consent can be obtained verbally

11. In regards to prescription privileges limited practice prescribers would work independently with limited prescriptive authority

12. The Health Insurance Portability and Accountability Act (HIPAA) was developed to protect protected health information

Twenty Things You need to Know About Current Issues in Psychotherapy 13. Under the Health Insurance Portability and Accountability Act (HIPAA) patients have a right to review and amend their own health records 14. The most ethical way to manage risk in psychotherapy is accurate and complete record keeping practices

13. Under the Health Insurance Portability and Accountability Act (HIPAA) patients have a right to review and amend their own health records

14. The most ethical way to manage risk in psychotherapy is accurate and complete record keeping practices

Twenty Things You need to Know About Current Issues in Psychotherapy 15. Licensure restricts the practice of a profession where as certification restricts the use of a profession's name. 16. When a mental health professional is engaged in multiple types of relationships with the same patient, this is considered an example of a dual relationship 17. F our out of 5 therapists report feeling sexual attraction to at least 1 client.

15. Licensure restricts the practice of a profession where as certification restricts the use of a profession's name.

16. When a mental health professional is engaged in multiple types of relationships with the same patient, this is considered an example of a dual relationship

17. F our out of 5 therapists report feeling sexual attraction to at least 1 client.

Twenty Things You need to Know About Current Issues in Psychotherapy 18. The legal case of Tarasoff I states that if the patient is at immediate risk of harming someone else, the provider has the duty to warn the intended victim. 19. Evidence suggests that therapists are no better at predicting danger than individuals in the general population 20. Practice guidelines such as those developed by the Agency for Health Care Research and Quality will likely be used more frequently to determine appropriateness of care

18. The legal case of Tarasoff I states that if the patient is at immediate risk of harming someone else, the provider has the duty to warn the intended victim.

19. Evidence suggests that therapists are no better at predicting danger than individuals in the general population

20. Practice guidelines such as those developed by the Agency for Health Care Research and Quality will likely be used more frequently to determine appropriateness of care