Professional Identity

Straws in the Wind
Don Durkee, Ed.S., LPC, NCC

“It’s a good thing couches are too heavy to throw, because the fight brewing among therapists is getting ugly.” This is the opening line of Sharon Begley’s recent editorial entitled “Ignoring the Evidence: Why do psychologists reject science?” Writing in the October 12 issue of NEWSWEEK, Ms. Begley speaks of an issue among “psychologists” (by which she clearly means therapists in general), and she refers to “years of research” on therapeutic outcomes that have divided the professional community. On one side of the argument are those who believe in evidence-based approaches to therapy (EBT), and on the other are those who view those approaches as leading to more mechanical and less personal forms of therapy.

The argument over evidence-based therapy has gone on for some time in the therapeutic community, with strong voices on both sides. At a recent Networker Symposium, Marsha Linehan, the developer of Dialectical Behavior Therapy (DBT), reportedly claimed that any clinician not using evidence-based methods should be considered guilty of an ethics violation. Yet Irvin Yalom, noted therapist, author, and lecturer in his book The Gift of Therapy has warned against the “EVT [empirically validated therapy] Bogeyman,” raising doubts about the research methods used or the applicability of this approach to in-depth therapy.

Not surprisingly, much of the impetus behind the promotion of evidence-based methods comes from insurance companies. In the name of establishing “best practices,” many of the major managed care networks are encouraging use of EBT, with practitioners regularly required to record client progress in some central data base. One company clearly states their “belief that patient outcomes are the most important indicator of quality” of the clinician’s work. It is not hard to envision a future in which authorizations for therapy and numbers of sessions approved would be made in anticipation of these “best practices.”

Whatever your position on the issue, it is clear that what has been until now an arcane discussion within the therapeutic community has finally crossed the line into the “mainstream media.” It is one thing for the issue to be debated in a clinical journal or at a professional conference; it is quite another for it to be a subject in NEWSWEEK. With all the public attention being paid to “health care reform” and the need for “greater efficiency and accountability,” it is increasing likely that counselors will soon be getting some pointed questions: How do you practice therapy? What methods do you use, and are those methods evidence-based?

We should also remember that the issue of EBT is just one of several that will soon be confronting our profession. As the major public voice for counselors in Georgia, LPCA must take an active role in making sure that the issues are clear and that the debate is thoughtful. It is equally important for all of us as members to study each issue carefully and be prepared to articulate our positions clearly to ordinary people. This is a time when our professionalism must be on public display. Each of us has a part to play. Let’s not wait until there are articles in TIME and U.S. News.

Counselor Safety in Private Practice

Counselor Safety in Private Practice

Confidentiality and the rights of clients remain the responsibility of clinicians. According to the Composite Board Rules 135-7-.01, a licensee’s primary responsibility is to the client. As such, clinicians serve as the vanguard of the rights and confidentiality of their clients. Clinicians follow the basic tenet of do no harm. Yet this basic tenet can create the potential for a clinician to encounter ethical dilemmas regarding safety and disclosure of confidential information.

Consider the following case: A male schedules his first appointment with a female clinician to receive counseling for his sexual behavior. During the first session, he exposed himself to the counselor after becoming aroused as he described his recent sexual activity. The counselor immediately terminated the session and requested the male leave her office. The counselor was unable to convince him to leave of his own volition and she contacted building security to escort the male from the building. The counselor filed a report with building security and local police, but remained concerned regarding her duty to warn should this male schedule with other female counselors and his behavior escalate to physical harm. What are the responsibilities of the counselor? Does “duty to warn” apply in this situation?

The most common example stems from Tarasoff v. Regents of the University of California in which it was determined counselors have the duty to protect third parties against whom a client may have made a threat and requires breach of confidentiality. This ruling has sparked great interest outside of California, and while enacted in several states it has not been implemented as law in Georgia. Therefore, counselors become legally and ethically bound to the laws and rules enacted by the Georgia Composite Board regulating the counseling profession.

According to rule 135-7-.03, subsection (2)4, confidentiality may be breached, “where there is clear and imminent danger to the client or others, in which case the licensee shall take whatever reasonable steps are necessary to protect those at risk including, but not limited to, warning any identified victims and informing the responsible authorities.” In this case, the counselor assumed the necessary responsibility to ensure her own safety and notified the appropriate legal authorities.

In this instance, the individual can be considered a criminal instead of a client allowing for the clinician to disclose identifying information of the male to police in order to facilitate their investigation. Yet the dissemination of his identifying information via mass communication with colleagues creates the risk for libel and the potential for distortion of facts. Vague examples of safety concerns may be discussed with clinicians in order to foster the development of safety plans. Clinicians should also contact their professional association to obtain additional support and guidance in developing safety plans and navigating the legal recourse for similar situations.

The Ethics Chair for LPCA’s Board of Directors, David Lane, will provide a follow up article to this email notification in the September edition of the LPCA newsletter to further discuss safety planning for clinicians. If you have additional questions or wish to comment on this email blast, please contact LPCA staff at (404) 370-0200 or LPCA@mindspring.com.

By Nicole Urbanek, License-Eligible, lpcaoffice@mindspring.com
LPCA Office Manger

Mental Illness

The Gringe Who Stole Christmas

This year those who suffer from mental illness will not have many gifts under the tree. In past year’s they would have nicely wrapped gifts of day treatment programs, respite care, job training, and state funded in-patient hospitalization beds. Now the tree is barren and empty. The only thing left is the memory of past years of fullness when all who asked; got what they wanted.

Georgia is the grips of one of the worst economic crisis in years. According to a November 19, 2008 document titled Hospital Game Plan Update, the state has the following four strategies to deal with the economic shortfall:
· Consolidate hospital populations
· Shift the front door from the hospitals to the community
· Privatized to construct new facilities
· Close some hospitals

The state says that this plan will:
Provide new hospital infrastructure to replace outdated and inefficient facilities
Expands and enhance treatment alternatives in the community
Position the state hospital to be used only after community options have been exhausted

In 2008 the state hospital system has 580 mental health beds, 588 forensic beds, 929 development disability beds, 56 child and adolescent beds, and 210 skilled nursing facility beds. By 2012, the state projects the numbers to be 450, 600, 250, 0 (zero), and 210 respectively. The state further wants to increase by 2012 the number of crisis stabilization beds 48% to 172 total beds, create six new social detoxification programs, increase the number of mobile crisis teams 154 % to 68 counties, increase the number of ACT teams 114% to eight teams with each team having a caseload of 70, and increasing the transportation budget to $700,000.

No one in the advocacy community questions the need for changes. What is in question is speed of the changes and how the state will implement this plan. Another concern is that in other states where privatization occurred it failed and the system left the most vulnerable without services.

Some say the mental health system in this state has reached a tipping point. The system has reached a critical mass. The system must change or many will suffer. All those who suffer with the pain and shame of mental illness need an advocate at this time to ensure the quality of their life. We need you. During the 2009 legislative session, the three biggest concerns for our constituents are the budget, the re-organization plan of DHR/MH/MR, and the closure of the state hospitals. Hopefully you can find some passion in one of these causes to fight for. Please join us in this fight.

Johnnie L. Jenkins, III, MA, NCC, RPT, LPC