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Patient Access to Records: The Invisible Confidentiality Right

By Bruce G. Borkosky, PsyD from Ethics & Risk Management: Expert Tips VII

Electronic Health RecordConfidentiality has been around since Hippocrates. In contrast, the patient’s right to obtain a copy of records (patient access) is a relatively recent concept. This may be a surprise, but patients have had a legal right to their records for only about 30 years. Prior to the 1970s, patients had no right to access their records. No state or federal statutes required it, and the AMA ethics code advised refusal of access. Some patients had to obtain a court order to gain access.

The APA has been a laggard here. The first mention of access rights occurred in 1992, but only in regard to test data and only as an exception to confidentiality. Psychologists could withhold records, except to patients; but psychologists were permitted to withhold access to patients if they determined the access was “inappropriate.” It wasn’t until the enactment of HIPAA that the ethics code began to address access rights.

Access Not Required by APA

Although HIPAA mandates access, official APA policy sees things differently. Here is a sampling:

  • The Forensic Guidelines state that a forensic patient has no right of access.
  • The Record Keeping Guidelines, the Association of State and Provincial Psychology Boards (ASPPB) Code of Conduct, ASPPB Model Act, Rights and Responsibilities of Test Takers and Guidelines for Test User Qualifications all refer to confidentiality but do not mention access rights.
  • Although the ethics code requires release of test data with a written release, records can be withheld by institutional policy or legal proceedings, courts and organizational clients. Finally, psychologists are not required to but “may” release records.

Practitioners Often Refuse Access

This position by the APA may be part of the reason that access to records has been – and continues to be – controversial and a topic of heated listserv discussions. Psychologists refuse to release records to patients, third parties, the courts, non-psychologists and attorneys, sometimes enlisting the courts in their efforts (although courts are rarely supportive). Denial of access is a top HIPAA complaint against health care providers. Psychologists are urged to refuse release of test data to non-psychologists.

Access is Required by Law

This denial of access is surprising, because state and federal laws require access. All states except three (North Carolina, Iowa and Wyoming) have laws requiring access. Further, for the vast majority of psychologists who are regulated by HIPAA, HIPAA preempts any state laws that might limit access.

Finally, patient access is consistent with ethical principles:

Autonomy

The ethics code uses unusual wording for Principle E (normally referred to as autonomy), perhaps to emphasize that respect for autonomy requires more than acquiescence to the patient’s choices – it’s a positive obligation. One should actively enable the patient’s capacity for free choice, including disclosing information to the patient that increases understanding, fosters decision making and nurtures their capacity as a free agent.

Privacy, confidentiality, privilege, informed consent and access comprise these information-based facets of the autonomy right. Patients decide to consent to services, choose to share private information with the psychologist and then they determine whether (and with whom) to release that information to third parties.

Psychologists demonstrate respect for these rights by obtaining written informed consent to treatment and written authorization to release information. Exactly as we demonstrate respect for the patient in handling their information in these ways, we should also respect the patient enough to let them know what information is contained in those records. Further, access is consistent with informed consent – a patient must know what information is going to be released to determine whether to release the records.

Non-Malfeasance

A number of scholarly arguments have been offered as reasons to withhold access. Some scholars believe that the patient might be harmed by the information in the records. However, there is little empirical evidence of such harm, and there is evidence of no harm. On the other hand, patients may be harmed when access is refused. Records may contain errors, other professionals may need the records to perform their jobs and the patient may need access in order to make important decisions. When access is delayed or denied, the patient’s health, legal rights and/or freedom may be derogated.

Honesty (Integrity)

Honesty refers to comprehensive, accurate and objective transmission of information, including patient understanding. When we withhold information, we convert our relationship with the patient from one of respect to paternalism; we make the patient dependent and vulnerable to a range of future harms. Others may wonder what we have to hide. Conversely, access to records increases openness and transparency and is itself clarifying.

Justice

Justice is a broad topic, far too wide-ranging for discussion here. In part, justice refers to fairness, protection of civil liberties, equal treatment, equitable distribution of services and guarding against bias and prejudice. Under various theories of justice, it can be argued that patients’ control over and access to their records, is just.

According to formal justice, equals should be treated equally. When some patients are permitted access to their records but others are not (e.g., clinical vs. forensic), equals are treated disparately and unjustly. Under Libertarian views of justice, patient-control over the distribution of records affirms the patient’s liberty and property rights. Courts have established the patient’s common law property right to the information in their records, so the transfer of this “property” is only just if it is freely chosen by the patient.

In summary, although required by law, psychologists often refuse to release records. Permitting access is the more ethical path, but it’s surprisingly absent from APA ethics and guidelines. Psychologists who believe that refusing to release records is ethical may face (in additional to legal sanctions) a serious ethical dilemma if working for an organization such as the Veterans Administration (using an internet-based patient access system). The APA should clarify this issue in future guidelines.

Related Article: Government backs down on some requirements for digital medical records

Ethics and Risk Management: Expert Tips VII is a 3-hour online continuing education (CE/CEU) course that addresses a variety of ethics and risk management topics in psychotherapy practice in the form of 22 archived articles from The National Psychologist and is intended for psychotherapists of all specialties.

Professional Development Resources is approved to offer continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board; the South CarolinaBoard of Professional Counselors & MFTs; and by theTexas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.

 

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Why Are Mentally Ill in Prison Instead of Treatment?

By Stephen A. Ragusea, PsyD, ABPP, from Ethics & Risk Management: Expert Tips VII

Recently on one of my psychology listservs, one colleague posted the following:

“I witnessed an inmate in a county jail who was acutely psychotic and was kept in solitary confinement for almost two years, naked, lying in his/her own urine and feces. There was no heat in the cell, and the human wastes leaked into adjoining cells. Numerous official and professional persons were aware of this poor person’s plight and no one did anything (or at least anything that was within their ability and authority) to end the inmate’s suffering. Apparently, this is acceptable practice here in Florida, as all persons were found to be practicing appropriately.”

Ethics, Psychology and the Prison MessUnfortunately, the situation described above by one of our colleagues is not uncommon. In my many years of work in prisons I’ve observed similar scenarios many times. I too have seen naked prisoners lying in their own filth. I’ve seen prisons where an entire block of 40 men was on suicide watch. I’ve seen a prisoner who was elderly, demented and paranoid sent to prison repeatedly after being prosecuted for making “terroristic threats.” I’ve seen a psychotic bipolar prisoner tied to a metal chair and drenched with a fire hose to make him “behave.”

As has been true for more than two decades, the United States incarcerates a higher percentage of its population than any other nation in the world. Most prisoners are under the age of 30 and approximately 15 percent are people who meet the DSM criteria for a mental illness. About half of that 15 percent are diagnosable as seriously mentally ill, suffering from problems like schizophrenia and bipolar disorder.

According to a 215-page report (ISBN: 1564322904) by Human Rights Watch, “One in six U.S. prisoners is mentally ill. Many of them suffer from serious illnesses such as schizophrenia, bipolar disorder and major depression. There are three times as many men and women with mental illness in U.S. prisons as in mental health hospitals.” One of the report’s authors, Jamie Felner, observed, “Prisons have become the nation’s primary mental health facilities.”

How did we get into this mess? Some of it started when politicians decided that they could get elected and stay elected by being “tough on crime.” They voted for mandatory minimum sentences, taking discretion away from the judiciary. And, although approximately half of these prisoners were convicted of non-violent, drug-related offenses, rather than voting for funding to pay for alcohol and drug treatment, our elected officials decided to spend our hard-earned tax dollars on building more prisons. The result of this national movement was that we currently incarcerate approximately 1 percent of our population. More than 2.5 million Americans now live behind bars. That’s the equivalent of every man, woman and child in the cities of Philadelphia, Columbus and Seattle.

A few years ago the Tallahassee Democrat reported, “Florida’s law enforcement and corrections systems are rapidly evolving into the state’s de facto mental health treatment providers. More often than not, our law enforcement officers, prosecutors, defense attorneys, judges and parole officers are being forced to serve as the first responders and overseers of a system ill-equipped to deal with an underfunded treatment system that’s stretched beyond capacity.”

To a large degree, the tax money for building and operating prisons was stolen from our public mental health system. Part of John Kennedy’s vision for Camelot included a national system of well-funded community mental health centers that would serve the mentally ill in their own hometowns, thereby permitting the closing of a well-developed system of state mental hospitals that had provided inpatient treatment for the severely mentally ill.

Those of us old enough to remember the 1970s recall an era of widely available, well-funded mental health care provided through local Community Mental Health Centers. Oddly enough, the systematic under-funding and disempowering of our Mental Health Centers coincided with the increase in funding of the prison system to support the “Get Tough on Crime” movement that spread like a well-intentioned plague from sea to shining sea.

Psychologists should lead the battle for prison reform. I would argue that we have an ethical obligation to do so. Specifically, I reference the preamble of our ethical code, which states:

“Psychologists are committed to increasing scientific and professional knowledge of behavior and people’s understanding of themselves and others and to the use of such knowledge to improve the condition of individuals, organizations and society. Psychologists respect and protect civil and human rights and the central importance of freedom of inquiry and expression in research, teaching and publication. They strive to help the public in developing informed judgments and choices concerning human behavior.”

As doctors of behavior, academic psychologists should be researching new solutions to our social problem of crime and punishment. Clinical psychologists who work in the system should be developing and implementing alternative treatment models for the imprisoned mentally ill. And all psychologists should be demanding government action to correct this inhumane, ill-conceived, foolishness. Can you imagine a hundred thousand psychologists remaining passively silent as 275,000 mentally ill Americans are mistreated? We are. Can you imagine psychologists saying nothing as prisons are turned into “the nation’s primary mental health facilities?” We have.

If you think these issues are important, say so to the leadership of your state and national psychological associations. Talk to your elected representatives. Contribute your time and energy to make things change. We can do better. It is our ethical responsibility to do better.

For more information, please read The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey

Ethics and Risk Management: Expert Tips VII is a 3-hour online continuing education (CE/CEU) course that addresses a variety of ethics and risk management topics in psychotherapy practice in the form of 22 archived articles from The National Psychologist and is intended for psychotherapists of all specialties.

Professional Development Resources is approved to offer continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board; the South Carolina Board of Professional Counselors & MFTs; and by theTexas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.

 

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How to Become More Resilient

By 

Bouncing Back: Resilience Can Be LearnedWe’ve all had the experience of a dark moment in our lives. Times where the sun didn’t shine, the rain fell in sheets along with our tears, and we wondered how we could possibly bounce back from it all. Yet, we do bounce back and move on — some of us more easily than others.

Good news! You can learn to be more resilient.

I was invited to a fundraiser for women in mental health last month. The speaker was a well-respected psychiatrist of 20 years and associate chief of psychiatry for our local mental health facility. She gave a moving talk on resilience, highlighting all of the scientific research behind it, and I did an inner happy dance for the confirmation it gave me that I have been on the right track for the last few years as I spoke about resilience. Dr. Alison Freeland covered three of my four essential components to strengthening our bounce-back muscles (my fourth being rooted in greater purpose or spirituality), but most importantly she suggested that indeed resilience can be nurtured and enhanced.

Why is resilience so important to me — a woman on a crusade to empower others into self-care? Because resilience is a state of being at choice, and being at choice means you have the power to direct your life as you see fit. Any time a woman is in the perspective of being a victim of her circumstances and is paralyzed by a diagnosis, or a toxic relationship or a dead end job, she is essentially giving up her power. By increasing our resilience, we can all become stronger to make the difficult choices and orchestrate the lives we want and love.

Practice these daily and watch your resilience blossom:

Mindfulness
Mindfulness is not just a buzzword to be bounced around, there’s actually a large body of science that supports its benefits. Mindfulness also doesn’t necessarily mean you need to incorporate a daily morning and evening hour-long meditation into your already over-scheduled life. Small things like taking a deep breath every time you swipe your smart phone to unlock it, or taking a moment to feel the water temperature and soap texture or smell the scent of the soap as you wash your hands, those are mindfulness moments. Being in the present moment is a mental workout so get in a good three sets of 10 reps throughout the day. And by all means, learn to meditate if you can fit that in too.

Healthy Body Habits
According to the World Health Organization a healthy dose of exercise is considered 150 minutes weekly of moderate intensity, which is slightly elevated heart rate that also makes you a bit short of breath. This is really not a lot of walking, running, biking or dancing. (Note this is not the amount of exercise required for weight loss. We’d do ourselves a huge favor to separate exercise for health and exercise for weight loss in our minds.) As for nutrition, in my opinion, if you are focused on getting the fiber intake recommended by the Institute of Medicine (Women need 25 grams of fiber per day, and men need 38 grams per day) you would be hard pressed to be short on any other macro or micro nutrient required for health, and you’d probably crowd out all the junk food from your diet as well.

Reach-out to Your Community
Community support is what human beings thrive on. We are meant to live in tribes, families, and groups with common interest. When we are in our states of despair we often isolate ourselves, which in turn just makes matters worse. Find a trusted few you feel comfortable being vulnerable with and have them be your allies in times of need. Quiet the voice in your head that shames you for needing help, and reach-out.

Do for Others
The quickest way out of a funk is to realize that someone somewhere has it worse than you. Something as simple as writing a note to a person in need, or as complex as volunteering or starting a non-profit, can empower us all. For some people, but not all, this greater purpose and fulfillment is also found in a spiritual practice and a sense of unity with humanity on an energetic or vibrational level. It is important thought that when you are doing for others that it’s from a place of genuine love and caring and not from a place of guilt or obligation. Resentment doesn’t build resilience, but feeling fulfilled and having a sense of purpose does.

Source: http://www.huffingtonpost.com/tammy-plunkett/bouncing-back-resilience-can-be-learned_b_7342158.html?ncid=newsltushpmg00000003

Related Online Continuing Education Courses:

Mindfulness: The Healing Power of Compassionate Presence is a 6-hour online continuing education (CE/CEU) course that provides you with an excellent understanding of exactly what mindfulness is, why it works, and how to use it.

Building Resilience in your Young Client is a 3-hour online continuing education (CE/CEU) course that offers a wide variety of resilience interventions that can be used in therapy, school, and home settings.

These online courses provide instant access to the course materials (PDF download) and CE test. Successful completion of the online CE test (80% required to pass, 3 chances to take) and course evaluation are required to earn a certificate of completion. You can print the test (download test from My Courses tab of your account after purchasing) to mark your answers on it while reading the course document. Then submit online when ready to receive credit.

Professional Development Resources is approved to offer continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board; the South Carolina Board of Professional Counselors & MFTs; and by theTexas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.

 

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Anxiety: Practical Management Techniques

By Lisa M. Schab, MSW, LCSW

Anxiety: Practical Management TechniquesNearly every client who walks through a health professional’s door is experiencing some form of anxiety. Even if they are not seeking treatment for a specific anxiety disorder, they are likely experiencing anxiety as a side effect of other clinical issues. For this reason, a solid knowledge of anxiety management skills should be a basic component of every therapist’s repertoire. Clinicians who can teach practical anxiety management techniques have tools that can be used in nearly all clinical settings and client diagnoses. Anxiety management benefits the clinician as well, helping to maintain energy, focus, and inner peace both during and between sessions.

Since one of the greatest obstacles to practicing anxiety management is finding the time and energy to actually do the exercises, one of the basic challenges in teaching these techniques is convincing the client that it is a realistic practice. Many people view adding anxiety management techniques to their life schedule as an imposition. Most are already overloaded with the responsibilities of daily life (which contributes to their anxiety) and the thought of having to add more responsibilities to that mix can appear a daunting or unrealistic task (and raise their anxiety even more). Therefore, this course is designed to provide a majority of techniques that can be used simply, in a short period of time, and can be incorporated into daily life with as little disruption as possible.

Anxiety management techniques are most effective when presented in a manner that gives the client the hope that they can actually practice them. Two key questions that help to achieve this are: “Do you breathe?” and “Do you think?” When the client answers, “yes,” you can then inform them that they are already practicing the two most powerful tools for staying calm. However, the way they are using the tools may be contributing to their anxiety rather than diminishing it. Success can be achieved when they simply learn to use their tools in a different way.

The two premises behind the effectiveness of these tools – breathing and thinking – are basic physiology and Cognitive Behavioral Therapy. Physiology tells us that the depth and speed of our inhalations and exhalations will affect the amount of tension in our bodies. The amount of oxygen flowing in and out of our bodies will also affect our ability to think clearly. Cognitive Behavioral Therapy instructs us that the way we think determines our feelings. The thoughts we choose at any given moment will directly and significantly affect our anxiety level.

Since breathing and thinking are behaviors that are practiced constantly, no matter where a client is or what they are doing, clients can then understand that they will have the time and the energy to use these two important tools realistically and practically in their daily lives. They need no special equipment, no scheduled appointment, no special block of time, and no particular location. These are tools that they carry with them and can use at every single moment. Two of the sections which follow – those on breath work and cognitive restructuring – address these physiological and cognitive techniques in detail. A great number of exercises in the other sections are also based on these two techniques.

Anxiety: Practical Management Techniques

4-Hour Online CEU Course

Learn more and earn 4 hours of continuing education credits by taking the Anxiety: Practical Management Techniques online CE course. Nearly every client who walks through a health professional’s door is experiencing some form of anxiety. Even if they are not seeking treatment for a specific anxiety disorder, they are likely experiencing anxiety as a side effect of other clinical issues. For this reason, a solid knowledge of anxiety management skills should be a basic component of every therapist’s repertoire. Clinicians who can teach practical anxiety management techniques have tools that can be used in nearly all clinical settings and client diagnoses. Anxiety management benefits the clinician as well, helping to maintain energy, focus, and inner peace both during and between sessions. The purpose of this course is to offer a collection of ready-to-use anxiety management tools. Course #40-12 | 2007 | 41 pages | 30 posttest questions

This online course provides instant access to the course materials (PDF download) and CE test. Successful completion of the online CE test (80% required to pass, 3 chances to take) and course evaluation are required to earn a certificate of completion. You can print the test (download test from My Courses tab of your account after purchasing) to mark your answers on it while reading the course document. Then submit online when ready to receive credit.

Professional Development Resources is approved to offer continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board; the South Carolina Board of Professional Counselors & MFTs; and by theTexas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.

 

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Louisiana OT License Renewal & CE Info

From the Louisiana State Board of Medical Examiners

Online CEUs for Louisiana OTs

Board-Approved Online CEUs for Louisiana OTs

Louisiana-licensed Occupational Therapists (OTs) and Occupational Therapy Assistants (OTAs) are required to renew their licenses annually and must complete 15 hours of continuing education (CE) each year in order to renew.

Professional Development Resources is approved to offer online continuing education to OTs by the American Occupational Therapy Association (AOTA #3159). Louisiana OTs may earn all 15 hours from the AOTA-approved online courses available @ https://www.pdresources.org/profession/index/5.

Popular Online Courses for OTs:

Improving Communication with Your Young Clients is a 3-hour online continuing education (CE/CEU) course that teaches clinicians effective and practical communication and conversational skills to use with young clients and their families.

Animal-Assisted Therapy (AAT) is a 2-hour online continuing education (CE/CEU) course that provides the information and techniques needed to begin using the human-animal bond successfully to meet individual therapeutic goals.

The Occupational Therapist in Long Term Care is a 2-hour online continuing education (CE/CEU) course that provides an overview of occupational therapy services in skilled nursing facilities.

Therapeutic Aspects of Running is a 1-hour online continuing education (CE/CEU) course that will equip healthcare professionals with the knowledge to encourage clients on developing a healthy individualized running regimen while preventing running injuries.

Autism: The New Spectrum of Diagnostics, Treatment & Nutrition is a 4-hour online continuing education (CE/CEU) course that describes DSM-5 diagnostic changes, assessment, intervention models, dietary modifications, nutrition considerations and other theoretical interventions.

Professional Development Resources is an American Occupational Therapy Association (AOTA) approved provider of continuing education (#3159). The assignment of AOTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by AOTA.

 

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Using Hypnosis With Children

By William C. Wester II, EdD

I often work with children and often employ hypnosis. A few anecdotes from my experience will show why I find that so rewarding.

Using Hypnosis With ChildrenChildren are developmentally in motion both physiologically and psychologically. They live in a land of discovery where ideas realize themselves and imagination prevails. Children are always in a creative and imaginative trance-like state.

Children have very creative and active imaginations. A child experiencing a problem generally wants help to move forward by learning a variety of skills that will resolve the problem – and children do not come to treatment with the same baggage of myths and misconception as adults.

To help clarify the myths and misconceptions about hypnosis, the therapist can send the child’s parents, prior to the first session, a brochure entitled “Questions and Answers about Clinical Hypnosis” (2013) Gahanna, Ohio: Ohio Psychology Publications Inc. Another good reference is My Doctor Does Hypnosis (Elkins, 1997 Chicago: American Society of Clinical Hypnosis Press).

The therapist is continually confronted with the issue of determining the most effective strategy based on the medical and psychological need as well as the child’s developmental level. The therapist must decide what level of distraction, hypnosis or metaphor would be most helpful.

It is easy to move from a distraction technique to an induction, especially in an emergency situation. A babysitter brought a young girl into the ER with a severe cut on her hand. She had been playing with her brother, slipped and put her hand through a window. She was hysterical with this injury and without her mother.

I happened to be on the psychiatry unit, and the chief of psychiatry said we were going to the ER. When we got there he basically said that I should “do my thing” to calm this girl down.

After putting on a pair of gloves I approached the girl, introduced myself, pulled her arm out straight and said “that’s the prettiest blue blood I have ever seen.” The girl calmed somewhat and said, “That’s not blue; that’s red,” at which point we were engaged in a discussion.

I then asked her to try something and close her eyes. “I wonder if you can use your mind in a creative way to find the right switch to your right hand. With your eyes closed just see all the wires going to your brain and find the one that operates your right hand.” (Meanwhile, the staff had started to clean the hand).

“As soon as you find the right switch let me know by raising this finger on your other hand,” I said. “That’s great and now for just a moment, turn that switch off so the doctor can fix your hand. You will feel pressure on your hand but you will not feel discomfort because you have your switch off.” (The ER doctor puts several stitches in the hand.)

“The doctor is finished now,” I said, “so you can turn that switch back on but you can still control the discomfort and keep it very low. When you open your eyes we can see if the blood was really red or blue.” She opens her eyes and immediately I said, “You were right and the color is red. Isn’t it great to have learned something new? You did a super job teaching the doctors about how you can control your switches.”

In older children hypnotic relaxation, imagery, arm levitation or eye fixation may be the best induction technique, whereas in younger children the TV technique, “Fluffy the dog” modeling, and the magic carpet imagery may be used.

It is important to remember that all hypnosis is really self-hypnosis and that the therapist is only the teacher or director in the process. Graduate students quickly learn that some form of induction (age appropriate) is fairly easy and the child will go where they need to go. The real work begins after the induction in developing various therapeutic strategies and appropriate suggestions.

I also use magic as a way to develop rapport with children. I never refer to hypnosis as magic even though I incorporate a story of a magic carpet or magic castle in some inductions. At the end of a session the child is given a simple magic trick to practice until the next session.

Click here to read more.

This article is one of many contained in The National Psychologist – May/June 2015 issue. The National Psychologist publication is intended to keep psychologists informed about practice issues. Professional Development Resources provides continuing education credits for reading the paper and completing a brief, online CE quiz @ https://www.pdresources.org/courselisting/category/1/22.

Professional Development Resources is approved to offer continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board; the South Carolina Board of Professional Counselors & MFTs; and by theTexas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.

 

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Legal, Clinical, and Ethical Implications of Legalized Marijuana

By Stephen Behnke, JD, PhD, MDiv, from Ethics & Risk Management: Expert Tips VII

Implications of Legalized MarijuanaRecently the APA Ethics Office was approached with a question: What implications does the legalization of marijuana in two jurisdictions have on psychology ethics? The question has no immediate or obvious answer.

Issues will undoubtedly emerge over time as psychologists work within these jurisdictions and between jurisdictions that have different legal approaches to the use of marijuana. Nonetheless, the question offers an opportunity to begin thinking about the implications of evolving jurisdictional laws that govern the use of substances.

A useful framework is to consider the question from three closely related perspectives: legal, clinical and ethical. This analysis first isolates a specific kind of question, and then examines how the different kinds of questions interact. Thus, the analysis offers a two-step process.

From the perspective of the Ethical Principles of Psychologists and Code of Conduct (2002, amended 2010), a central standard is 2.01(a), Boundaries of Competence: “(a) Psychologists provide services, teach and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study or professional experience.”

The issue raised by standard 2.01(a) is whether it is within the boundaries of the treating psychologist’s competence to work with an individual who is using this particular substance. From the perspective of the Ethics Code, there is no distinction among substances – for example between marijuana and alcohol.

The psychologist must have the appropriate knowledge and skill to treat an individual with the particular individual’s pattern of use or gain the requisite knowledge and skills in the ways that standard 2.01(a) identifies. For this reason, there is an inextricable nexus between the ethical and the clinical, insofar as the Ethics Code says that the psychologist must have the appropriate clinical competence. New laws on the use of a particular substance do not seem directly relevant to this aspect of the analysis.

Ethical standard 2.01(f) may bring in the law in a manner that standard 2.01(a) does not: “(f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.”

Standard 2.01(f) places the ethical mandate for competence into forensic contexts. In a forensic context, the legal status of a substance that a client is using may be highly relevant to a forensic assessment.

Consider a psychologist who is conducting a child custody evaluation. Two parents live in separate jurisdictions, one of which has legalized the use of marijuana, the other has not. Both parents use marijuana in similar ways regarding the amount and frequency. The evaluator may find it appropriate to take into consideration that in one jurisdiction, the parent is using a substance that is illegal.

In this scenario, clinical considerations regarding substance use may be less relevant – if relevant at all – in comparison with the legal considerations of a parent who is engaging in an illegal activity. The clinical perspective may enter the analysis when the psychologist poses the question: Why would an individual engage in a behavior that may be directly contrary to that individual’s stated goal, i.e., maximizing access to his or her children? In this instance, the legal, ethical and clinical questions converge.

One can easily imagine other types of assessments where the legal status of an activity could be relevant. Ethical Standard 9.01(a), Bases for Assessments, states: “Psychologists base the opinions contained in their recommendations, reports and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings. (See also Standard 2.04, Bases for Scientific and Professional Judgments.)”

Standard 9.01(a) is not limited to forensic contexts. For certain jobs, knowingly engaging in activities that are illegal can be perceived as a reflection of one’s judgment. This consideration may be especially important for assessing individuals for leadership positions. Again, the legal, ethical and clinical converge, insofar as ethical standard 9.01(a) states that it is appropriate to take the legal status of an activity into consideration when such information substantiates a psychologist’s recommendation, report or diagnostic or evaluative statement. Likewise, evaluations in a criminal context may depend to a substantial degree on whether an individual is abiding by the law or engaging in illegal behaviors.

How the evolving legal status of marijuana will affect psychologists’ work is an interesting and important question that has no immediate or obvious answer. The nuances and contours of the question will necessarily emerge over time, and the APA Ethics Office will follow the issue with interest.

social stigmaOne especially intriguing area will be that of social stigma. Although social attitudes toward marijuana are changing, it is still viewed with suspicion – much more so than is alcohol – by a substantial segment of our society. It will be important to examine how such attitudes “seep” over into evaluations of marijuana use even in jurisdictions where it has been legalized.

Ethical Standard 2.04, Bases for Scientific and Professional Judgments, states: “Psychologists’ work is based upon established scientific and professional knowledge of the discipline. (See also Standards 2.01a, Boundaries of Competence, and 10.01b, Informed Consent to Therapy.)”

Part of the challenge for psychologists in jurisdictions that have recently legalized marijuana will be to examine the extent to which their work – grounded in research, data and clinical experience – is interpreted and applied by decision makers whose attitudes may be influenced by factors that do not have a basis in the “established scientific and professional knowledge of the discipline” of psychology.

When psychologists have a reaction of “Wait, that’s not what I was saying about the research,” they may consider ethical standard 1.01, Misuse of Psychologists’ Work:

“If psychologists learn of misuse or misrepresentation of their work, they take reasonable steps to correct or minimize the misuse or misrepresentation.”

Psychologists may look to the research regarding marijuana to see where and how social attitudes deviate from the data. Although it is much too early to know exactly how evolving marijuana laws will affect the application of the Ethics Code, it is reasonable to assume that ethics educators across jurisdictions will have ample opportunity to think about this interesting ethical question as time goes on.

Ethics and Risk Management: Expert Tips VII is a 3-hour online continuing education (CE/CEU) course that addresses a variety of ethics and risk management topics in psychotherapy practice in the form of 22 archived articles from The National Psychologist and is intended for psychotherapists of all specialties.

Professional Development Resources is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. Professional Development Resources maintains responsibility for all programs and content. Professional Development Resources is also approved by the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; theOhio Counselor, Social Worker & MFT Board; the South Carolina Board of Professional Counselors & MFTs; and by theTexas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.

 

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