 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. So I'd like to welcome everybody to today's presentation on common ethical violations. And I'm going to try to make it so it's a little bit more positive than talking about all the things to don't do. And we'll talk about some things we can do instead. But we do want to hit some of the highlights and look at some of the things that may have changed over the past two years since your last renewal. We will explore ethical guidelines with respect to multiculturalism, confidentiality, informed consent, documentation, and one of my favorites discharge versus abandonment. Ethical guidelines. We want to act in the best interest of clients at all times, which means acting in good faith in the absence of malice. We say that and of course we're thinking, yeah, of course, why would we do anything else? But a lot of times our ethical violations are inadvertent. We don't set out to try to hurt a client. We don't set out to try to do something that is harmful to a client, but somehow it happens. So we want to think before we act and as we're in a situation and developing policies and procedures for an organization, we want to think ahead and say to ourselves, what is the probability that something that we're doing could be in somehow in some way harmful to a client? And you know I'm a big proponent of trauma-informed care. So using that as an example, when you're creating policies and procedures for intake, I worked at a residential facility and when clients would come in, they would bring their bags in, they would go to the nurse's office, they would have to have all of their stuff searched, then they'd have this nurse who they'd never met before taking their blood pressure, doing all the basic, you know, stuff that we need to do for medical intake. But for people who had had a trauma history, that was not the most welcoming and that was kind of an intimidating sort of situation. So we looked at changing how that happened and the ways that we went about doing stuff. I mean even I as a clinician and then a director felt very invasive when I would have to go through their stuff and it had to be done because people did try to bring contraband into the facility. However, there was a difference between rifling through it indiscriminately and trying to be somewhat cognizant of how the person felt, you know, you don't want to go through their skivvies in front of five people that they've never met before. So maybe doing it in a situation where there's a little bit more privacy. So thinking about things when you're creating policies and procedures and how might this feel to a client? How might this impact a client? When we talk about the absence of malice and I talked about this a little bit last week, if you happen to be in a program that, and this is very, very true in substance abuse programs, but it's also true in mental health programs. If a clinician is not skilled or comfortable in handling certain diagnoses, sometimes the clients can feel like they are being judged or that the clinician is that they're not able to be helped because the clinician is like, well, I don't deal with that. And that's true when a mental health clinician says addiction. I don't know what to do with that. I'm going to have to refer you out instead of identifying that, you know, yes, that is a different diagnosis and there are different ways to handle it. And in order to best handle it, let's see what we need to do according to the Minkoff model. If someone is presenting with high symptomatology of mental health issues and low symptomatology of addiction issues, you don't necessarily have to refer out. You can consult and say, okay, this person is evidencing some behavior of, you know, binge drinking or something where it's not to the point they're substance abuse or their addiction is not to the point of requiring intensive care so it can probably be managed in a mental health primary setting. But we want the client to feel like they're not being judged. The same thing is true in addiction settings. If someone is not willing to embrace the 12 steps. A lot of addiction settings are 12 step based and they don't want to deal with anything else, which is from a, you can look at it from a multicultural perspective or a malicious perspective and that's kind of a weird word, malicious. But if we tell people that if you don't conform to our ways, then we're going to kick you out of the program, that seems pretty malicious to me. So we want to look at how can we be most inviting and accommodating to people's individualized needs. And if you're not familiar with addiction treatment, there are options to 12 step programs. There are cognitive behavioral approaches. There are spiritual approaches. There's a whole bunch of other stuff besides just 12 step. Anyhow, we want to inform clients of possible limitations on the counseling relationship prior to the beginning of the relationship. So what are the limitations? What can I and can I not do? But also what limits of confidentiality do I have? So before somebody comes in and starts spilling their guts and maybe says something that they don't want to say, they know that what our reporting requirements are. They know what we're going to have to report. And sometimes, you know, as a clinician, I'm like, well, I would rather know so I could intervene. But I've got to remember that the person in sitting in front of me is my client and the person sitting in front of me is the one for whom I'm serving at this point in time. So it's not trying to figure out any person that that person is harmed is trying to figure out what to do in the best interest of the person sitting in front of me. So in that vein, I'm going to let them know ahead of time that if you tell me about child abuse and you know, go through the whole list of things that I'm a mandatory reporter for and reasons that I may have to break confidentiality. We want to increase awareness of our own personal values, attitudes and beliefs and refer when personal characteristics hinder effectiveness. Now this is a huge hornet's nest. In Tennessee, there was a bill that went through the legislature that said that if a client of a different religious background comes to a clinician and they obviously have different religious backgrounds and the clinician is not comfortable treating that client because of the religious background then they can refer out and there was a lot of discussion about this, but ultimately it passed and so you know, it is what it is. But we want to look at the personal characteristics and if that person felt that strongly, would they have been able to be beneficent and non non non malfeasance and all those other things and faithful to their clients and loyal to their clients and all that kind of stuff. So we want to go through all those ethical guidelines and say, can you handle this? Can you put on your counselor hat and step out of your belief system as a Christian or a Muslim or whatever your belief system happens to be and you know, join with this other person with their belief system. There are also certain things that or certain issues if you will that you may not be willing to treat if you were a victim of sexual abuse as a child dealing with someone and helping them work through issues because they were an abuser may not be something that you're capable of fully doing in the best interest of that client at that point in time. So being aware of where you stand with your own issues and how comfortable you are looking at a client who may have who may resemble people that created issues in your past. Most of us have gotten over, you know, a lot of our stuff. We've been able to understand it, but there are still some enduring things that you may not be able to get past and the ethical guidelines say, you know, if it comes down to you cannot get past it, then it's ethical to most ethical to refer, but you want to do that early in the relationship. You don't want to wait until you're four months into it and go, you know what, I don't think I can really deal with this. And every once in a while something may come up that changes or the client drops a bomb on you and you're just like, okay, well wasn't expecting that. And then you've got to figure out if it's something you can deal with and with good supervision and consulting. Maybe your state ethics board, most ethics boards have a consultant who can say, you know, this is what you need to really think about. You can decide whether it's something, whether it would do more harm to refer the client at this point or try to treat the client with supervision. We want to actively attempt to understand the diverse cultural backgrounds of the clients with whom we work and our own cultural ethnic racial identity and its impact on our values and beliefs about the counseling process. So that's a lot of stuff. So basically we want to understand ourselves and what do we bring to the table and viewing everything as an interactive system. You know, when we walk in when I walk into a room as a middle-aged white female with a degree a higher education degree, how does that impact the situation with any particular client? How do I change the situation just by being me? And that doesn't mean I can't be me, but I do have to understand my impact on other people. Think about when a doctor walks into a room and a lot of people have some anxiety about white coats, white coat syndrome. Some a doctor walks into a room. They've got a lab coat on. All of a sudden people start to feel inferior because it's like, well, that person's a doctor and we can't, you know, the doctor knows best. Not, you know, I've lived in this body for 45 years. I think I know what's going on. So you want to look at what impact does your presence have? Maybe it's not you. Maybe it's what you're wearing. Maybe it's the decor in your office. Does that mean you have to change that? Not necessarily. You need to look at your clientele and consult your ethical personal ethics and figure out what it is that you can, you feel comfortable doing. And what, what, wow, can't speak today. What is it that you want your clients to feel comfortable saying, doing, being? So if you want your client to feel comfortable walking in your office and being of a different religion and your office happens to be just decorated in heavily Christian themed stuff. What does, what impact does that have? And how can you discuss it? I had one supervisor that I worked with who was a Christian counselor and he worked for a Christian counseling agency. So it was very obvious from the beginning that, you know, this was a Christian counseling situation. But he ended up working with a patient who was of the Muslim faith. And, you know, because it was a Christian counseling agency, she knew what she was walking into when she walked in there. And instead of butting heads, they talked about just what each faith thought about certain things. And he was interested and inquisitive about, okay, so what does your faith say about this? Because a lot of the issues they were talking about did revolve around her faith and what she believed in the decisions that she was making in her life. So we do want to understand our clients. If we don't understand, I came from a area that was very, very heavily Krishna and I had no idea about the Krishna religion. So when I would have a client come to me who happened to be Ari Krishna, we would talk about not only their thought path not only their thought patterns, but in what way their religion and their faith was impacting their decisions, their thoughts and because I'm not wanting to necessarily impose, well, not necessarily. I'm not wanting to impose my values and ways of thinking on them. So it's important you inquire. You don't have to know everything about your patient's ethnic background, their racial identity, where they came from. Heck, you won't. They walk into your office and you may not have any idea about where they came from, whether it was from, you know, somewhere in the middle of Tennessee or Detroit or Washington, D.C. Just by virtue of where they come from, geographically, they are going to have some values and some thoughts and some experiences that have shaped how they view the world that are probably going to be different than yours. You know, I've never lived in a big city. Big cities scare me because I get intimidated with all the traffic and everything. But when I work with someone from a big city who's having difficulty adjusting to, you know, rural America, you know, we talk about that and what's different here? What do you miss? We want to function within the boundaries of personal competence and be aware of our personal skill levels and limitations. If you are using a technique, make sure that you are competent in that technique. Don't just kind of go, well, I think I'm going to start doing whatever. Make sure that you're competent. Make sure that you know what you're doing. Get supervision. If you're starting a whole new technique, like if you're learning dialectical behavior therapy and you're using it as a protocol, make sure you get supervision. If you are trying to use experiential therapy, get supervision from someone who is skilled in experiential techniques, because I can tell you, sometimes you try an experiential activity and it doesn't go the way you expected. And having someone to process that with is very, very helpful and understanding what you're going to be able to start when you do it. Along with that, be aware of any activities that you do, going back kind of to the first slide, which may trigger trauma memories from your clients, turning down the lights, closing your eyes, saying prayers, meditation. Sometimes any ritualized opening or closing of a session can trigger traumatic memories for people. Be fully able to explain why you do what you do. And this isn't just during session. This is, you know, in your professional life when I was at the residential facility, that was sort of my battle cry with my staff. If you're going to ask the client to do something or tell them to do something, you need to have a rationale, not just because I said so. If they need to do chores, why do we have them do chores? If they need to go to a meeting, why do we have them go to a meeting? And be able to explain the rationale behind it so they understand. They may not like it. Especially like the two examples I gave, chores and meetings. But we could also work with the client at that point and thereafter about incorporating, understanding why that's important to their treatment. And if that particular intervention was not appropriate for some reason, i.e. the meetings, what else could you do instead? And why may you need to go to the meetings for right now? Because like I didn't have the staffing to leave six people back at the facility and take the other 28. So we would want to explain why we were making clients do particular things. Encourage family involvement where possible when working with minors in sensitive areas that might be controversial. And I would also expand on this to say encourage family involvement where possible period. When you have someone coming to treatment, they're working hard and they are going to make progress exponentially. And the people that they live with, the people that they interact with, their family, their friends are not going to make the same sort of forward movement at the same time. So it's like the client starts a race and they start running and they get a hundred yards out and they're starting to change and they're starting to make progress and everybody else is still back here doing the same thing. And a lot of times they become very confused when your client starts acting differently which inadvertently tries to bring them back into the fray. They're like, you know, when we do this, you're supposed to do this. This is how the system works and your client is going, No, you know, actually, I'm different now. So we want to encourage family involvement when you have someone in residential treatment. It's extremely obvious when you have someone discharge and the family hasn't been to any treatment, any family education, any anything, their behaviors, their expectations, their understandings and their dysfunction has remained the same. And especially in addiction, addiction is a family situation, a family disorder because they have adapted their behaviors to accommodate the addict for so long. Now, when this person comes out and they're not behaving the same way, it upsets the apple cart. So we want to encourage family involvement in the treatment process. Now, family is loosely defined. That's whoever the person feels is their family. It doesn't have to be a blood relative. Who is it that you live with that you think may need to be involved? Who is it that you would call in two in the morning if you're having a problem? How do you define family? And those are the people that we want to encourage to be there so they can be as supportive as possible of the recovery process. Follow written job descriptions. Sounds like a no brainer there. Be sure what you are doing is defined as an appropriate function in your work setting. Not everything you do is an appropriate function at every work in every work setting. So make sure that you are keeping that in mind. You know, having someone do yoga may not be appropriate in your work setting if you are an individual therapist, even if you are a certified yoga instructor. So be aware because there's a lot of liability that comes to your organization if you start acting outside of your job description. Read and adhere to ethical standards of your profession. I would assume. I would hope that we all did that. Consult with other professionals. Please know who some other professionals are in your area. If you aren't in a situation where you're in a in an agency where you have two or three people like right down the hall, you can go talk to know some professionals that you can call up and go, I've got an ethical dilemma or I'm stuck with this client and I wonder if you could consult with me. Obviously, you can maintain confidentiality of the client and all that happy stuff. But do have a network that also prevents you from getting burned out because other professionals can say, hey, you know, I noticed that you seem to be struggling with a lot of clients lately. Join appropriate professional associations. Read publications. Participate in professional development opportunities. Stay up to date on what's going on in your particular field. Not only with techniques to use with clients, but what are new developments that are happening? For example, when I got licensed way back when the NCMH CE didn't exist. So once you got licensed, you were able to diagnose and treat and write treatment plans and all that kind of stuff. And then what was it five, eight years ago? The NCMH CE came up and a lot of states started saying, well, even if you're licensed, unless you have this extra special designation, you can no longer write treatment plans or diagnose people. So that's a particularly important thing to be aware of. And ethically as well as legally, you need to be aware of it. Stay up to date with laws and current court rulings, particularly those pertaining to counseling with minors. What do they have to have parental approval for? What are the limits of confidentiality? Handling suicidal and homicidal clients. What are the current best practices in terms of identifying whether there's imminent danger to sell for others? And dealing with clients who have HIV, especially those that have HIV and are having unprotected relationships with other people. What is the ethical guideline for telling those people, for warning those people? What is the legal guideline? In some states, it is a felony to break confidentiality, to tell someone that your client who has HIV positive is tell one of their partners that the person is HIV positive and having unprotected sex with them. So make sure that you know the laws as well as the ethics and how to kind of balance the two for your state. Always consult with a knowledgeable attorney when necessary. I've had a lot of people go, well, attorneys are expensive and I don't work for an agency. How do I do that? Well, actually it's more affordable now. There are services out there where you can subscribe and you pay a monthly fee to basically have this legal service on retainer. And when you have a question, you call them and you're able to talk with an attorney who specializes in that particular area. I've used this for my business for many, many years and it's been invaluable because I know that I can call and get an attorney's opinion pretty much at a moment's notice and it doesn't cost me anything else besides my monthly dues to them. You also have the ability to consult with ethics boards and sometimes your insurance companies will also have a legal advisor that you can call and go, this feels a little hinky to me. I want to run it by the attorney. So check with your insurance provider and see if they also have somewhere you can consult with an attorney. Okay, let me see if I can get this to come up right here. And of course not. So we're just going to move on past that. This 10 legal identifies a lot of ethical violations and their statistics looking at how frequent frequently they actually happen. And guess what? Sexual relationships and dual relationships still rank way at the top of the ethical violations and reasons people are getting their licenses revoked. Also up there is unlicensed practice. Unlicensed practice falls. It's not just you're a counselor. You're working with a client in counseling. Well, you're a licensed counselor. So that's licensed practice. Yes, it is, but if you overstep your bounds and you start providing nutritional prescription or recommending supplements they take and anything that would be considered a prescription even if it's not written or oral. If you recommend, if you strongly suggest then you're crossing over into potential unlicensed territory and you've got to figure out for your own self ethically whether you know handing them a book about something steps outside of your bounds of practice. My personal opinion most of the time, I mean depends on the book of course is if I'm directing them to resources to educate themselves about something that's not prescriptive whereas if I say well it seems like you're suffering from X, Y, and Z so why don't you start taking these supplements and exercising four times a week. That's definitely outside of my scope of practice. Understand what constitutes a multiple relationship. Whose needs are being served and is the client being exploited? One area that I see this a lot is when agencies especially I really haven't seen it in private practice ask and I use that term kind of loosely pressure clients into giving testimonials or going and giving speeches somewhere. Most clients don't feel like they have the ability to say no so it's important because we have that authoritative we have that power over the client. It's important not to put them in a position where they feel like they might be exploited. If you want testimonials you might put a note out in the front lobby saying anyone who would like to give a testimonial contact you know whomever in the front office and we can definitely accommodate that but if you put a client on the spot and ask them would you please give a testimonial that could potentially be considered exploitive. Protect confidentiality discuss limits of confidentiality at the beginning ensure safe storage of records now I'm going to go off on a tangent here on digital records. It is very very important that you understand where all your stuff is stored. A lot of times people's laptops or or PCs. Don't have full hard drive encryption and you're like well the file that I store all this stuff in all my documents in is encrypted well that's great that is good that's awesome. However there are a lot of temp files that also contain that information because your computer backs up what you're working on every you know three five twenty minutes whatever it's set to so those temp files are not in that secured location and if you send anything into the printer anything that was sent to the printer is actually stored in yet another location that again is not encrypted unless your hard drive is full drive encrypted. So in to ensure state safe storage of records make sure any digital computers computers devices that you use have full encryption. Know your fate that federal and state laws about this is it well golly whether there's laws requiring disclosure about certain things what do you have to disclose if your records are breached when do you have to disclose. If your laptop gets lost do you have to disclose it you know most of the time it's yes but because of HIPAA laws you need to know when you need to disclose information obey mandatory reporting laws you know kind of self explanatory there. Obtain informed consent at the start of treatment a lot of you might be going well yeah unfortunately and I understand where it comes from you don't want to sit down with the client and go hey good to meet you let's do 30 minutes of paperwork and then we'll start talking about you but right now it's all about me because it feels very very impersonal and we want to be personal with our clients. So it's a little bit of an art to navigate but we want to make sure that we bring somebody in we get them so they're sitting down and feeling comfortable but before we start going into all their stuff we do want to have them sign their documents understand confidentiality and sign their informed consent. We want them to know what type of treatment is going to be provided and any alternatives a lot of times clinicians just say okay so we're going to sign you up for intensive outpatient treatment and this is what it's going to look like instead of saying my recommendation would be for intensive outpatient treatment this is what it would look like but you have other alternatives you have outpatient you have residential you have you know any other options that you might have making sure the client knows what their array is we want to let them know the cost and expected duration of treatment so it's not a shock for them and confidentiality identify your client and role so if an organization sends one of their employees to you for you to do an assessment or if probation and parole sends one of their probationers over to you to do an assessment who are you hired to help and what's expected of you who is the client and what are the limits of confidentiality document properly the guidelines at APA dot org are really helpful for identifying all the things that really should be in your records including your informed consent confidentiality demographic information what should be in your notes and your assessment so I'm not going to go over all that here because that's you know basic documentation 101 but it is good to review periodically to make sure that you're getting it all into your records because it's easy to become a little bit lax on some of the stuff that you know you don't use all the time practice where you have expertise some specifics to include in documenting therapeutic interactions according to the guidelines and ethics experts this is stuff that we often forget if you're in private practice especially it's easy to start getting lax and taking fewer and fewer notes I've worked with some clinicians who've been in private practice for a while whose notes are you know literally half a page for the entire assessment versus clinicians who just started out who end up writing something close to a dissertation so what things have to be in there identifying information and the date of first contact that way you can identify when this relationship began relevant history risk factors medical status and attempts to get prior treatment records attempts to get prior treatment records is often not in there but it's important to show that we attempted to do it in order to ensure continuity of care it's also important if you're working under insurance companies for level of care guidelines generally that's one of the things they require dates and service of fees dates of service and fees so when did you see this person what was the charge what was paid one of the things or risks for getting sued is when patients start running up a really big bill and we can talk about potential motivations for that but they found a direct correlation between the likelihood of getting sued and the outstanding balance of the patient who is suing you make sure you document what you're doing how often you're doing it how often you're getting bill sending out bills etc. You want to have diagnostic impressions assessments treatment plans consultation summary and supporting data and progress notes okay you know that seems self-explanatory one thing that you know I often don't include and I'm going to start including in my notes is not only the treatment chosen but the treatments that were considered and rejected that goes back to that informed consent and presenting all the options but identifying why the person declined the other avenues of treatment. This is especially true if the client declined the treatment that you recommended it's not uncommon in addictions for us to recommend something like intensive outpatient and the client to say no not ready to do that I'll do once a week outpatient and self-help groups. Okay if we don't believe that's going to do harm and obviously we can't force them to do any sort of treatment. We will document why they chose that why they declined our recommendations and you know so on and so forth that way if it ever comes back we can prove that we tried to get the person to enroll in this level of care but it was declined. Some specifics to include in dark documenting therapeutic interactions informed consent consent to audio tape or videotape so even if you're only audio taping or videotaping for your own personal edification and your own self supervision the client needs to sign an informed consent release of information and documentation of any releases this is something that is overlooked a lot releases of information not so much I mean we're good about doing those but a lot of times we overlook the fact that we are required every time we release information on a client to document to whom that information was released the date and exactly what was released so if the client ever wants an accounting of disclosures we have a sheet in their file that can say we provided this information to this person on the state. It's important in agencies to do that to relevant telephone calls and out of office contacts so if the client calls and says I'm not going to be able to make my appointment or they call and they're in crisis we need to document it doesn't need to be this huge thing but there does need to be a space in the chart to identify that you had contact with that client on that day. Follow-up efforts when clients drop out of site or drop out of treatment. If they just drop out you can't just discharge them and then never contact them again that's we're going to go into abandonment but that kind of falls it under abandonment if a client drops out of site we don't know whether they tried to commit suicide we don't know whether they weren't happy with our services we don't know if they're doing better we don't know and in order to be faithful to our clients and try to do what's in their best interest we at least need to follow up and provide them with referrals provide them some sort of closure let them know they're being discharged they may not answer your phone calls they may literally just kind of drop out and you can't find them you try calling and you don't get through so you need to send a letter that says something to the effect of I haven't seen you since so-and-so date on such-and-such date you will be discharged if you don't contact the office at blah blah blah here are some referrals you don't want to just kick them out you want to give them referrals to make sure they're safe and then send it to their last known address it's not ideal but you're doing the best you can we're not going to hire a private investigator every time someone drops out of treatment but we do need to follow up it also communicates to the client if they dropped out because they didn't feel like that like they were making progress or whatever the reason it communicates to them that you care and they're important which sometimes is enough to bring them back in you want to have enough details in your file so if another provider needs to take over in your absence they can when I was pregnant with my son I ended up having him at 29 weeks so obviously I wasn't planning to go on maternity leave for quite a while longer and all of a sudden somebody else had to walk in and pick up my caseload so it was important that my notes be sufficient that the next clinician could come in and at least have a general idea about what was going on with each client and what their treatment goals were etc know the difference between abandonment and termination treatment can be discontinued when clients are not benefiting from treatment anymore kind of should be discontinued if clients are not benefiting if they've reached maximal gains at this level of care then they need to be discharged whether that means referred up to a higher level of care referred down to a lower level or just plain discharged we don't want to keep them in if they're not benefiting from treatment if they're not benefiting but they're still symptomatic we also may consider a referral may not we want to discontinue treatment if the client may be harmed by treatment maybe they're recovering from addiction and all of a sudden you hit some trauma issues and you know the client is really struggling to stay clean and sober with dealing with this trauma stuff and you're their trauma counselor not their addictions counselor because they've got to so you may want to look at is it ethical and is it in the client's best interest to keep hammering away at this trauma stuff right now or do they need to get some more clean time before they can handle it discharge them if they don't need therapy anymore if they're doing well we wanted to we want to support the fact that they're doing well and go hey you know what you're doing awesome now I'm here if you need anything however I think we can start moving towards discharge and with most of my clients I don't go from once a week to nothing I'll go from once a week to twice a month and then maybe one or two once a month sessions and then they're discharged unless they start having more problems but 90% of the time they wean off and they don't need that second monthly appointment they're just they're good pre termination counseling involved the client in the process according to all level of care guidelines the insurance regulations for how to get paid they all say discharge planning begins added mission what does that mean that means if the client walks out of your office today and never comes back they need to have some resources they need to know what the next step might be so discharge planning starts as soon as they walk in we say you're probably going to be with us for two months we want to accomplish these goals and then here are some other resources that you may want to tap into during treatment abandonment is when the client drops out of treatment and the therapist doesn't follow up or the therapist discharges the client without appropriate referrals if you for whatever reason have a conflict with the client and you decide you need to discharge them and you don't give them referrals you're just like nope this isn't working bye bye you fire them if you have not give given them referrals and ensure to transition then it's abandonment if the client is in an emotionally distraught state if the client is struggling if the client needs therapy and you just kick them out then you are not doing what's in the client's best interest stick to evidence when giving an expert opinion conducting assessment or documenting or documenting when you're doing your documentation always assume that your client is going to read it now chances are they won't but if you assume that then if your clients read it then they won't be hurt by it you want to always stick to the facts you know client is depressed as evidenced by client is struggling with XYZ symptom as evidenced by try to keep it as objective as possible there is a section for interpretation you know your clinical impressions and all of that but try to stick to things that are supported by observable evidence also be aware of what you do and don't know you know if you don't know something maybe you don't know what's causing a particular symptom or you don't know all the details of your clients past don't assume you do and be very clear about what you do and don't know ethics involves constant awareness of the clinicians own motivations and attention to the client's best interest effective documentation can eliminate many sources of confusion at the beginning and can support us in legal situations good documentation means it happened if it's not documented it didn't happen but the better the documentation the more thorough the picture is for whoever else the outside parties that are looking at it to go yes you did everything that a reasonable clinician in your position would have done annually read any changes to your state's statutes to ensure you're not violating any legal and or ethical dictate you can usually go to your licensing board's website and you can find a list of anything that was changed in the prior 12 to 24 months any rules that were changed generally on the front page and highlighted from what I've seen on the different states when in doubt consult other professionals ethics committees or your attorney and or your attorney okay so a question came in do you have any thoughts on the concept of what is in writing is discoverable in a lawsuit versus keeping good notes yeah that always gets really tricky and the safe answer is to say always consult with your attorney when you're questioning whether something should be in a in a clinical record when I do my clinical records I put in as much as is necessary to support their diagnosis to support the treatment and that's factual but a lot of times when I'm working with clients if there's something that I'm questioning putting in the record because I think it might be too personal for them I ask them I'm like you know I want to document this in in your record but how do you feel about this being down there in in black and white now as far as if it's discoverable in a lawsuit if I'm concerned about something being in a lawsuit then I need to look at what why am I concerned that there might be a lawsuit if I'm working in a divorce or a custody case then I'm going to probably be more of more objective rigorously objective in my in my notes but you know I think it's also important to make sure that we paint a clear picture for ourselves and for the clients of what's going on one thing that I do with my clients partly because I find it's I find that they find it empowering is we write notes together I saved the last ten minutes of a session and we go over you know okay what did we talk about today and we'll review what we talked about will review their progress on their treatment plan goals and we'll review their goals for the next week we'll write all that down together so they know what's in the notes so there's nothing scary about this file that's sitting on my desk and if they have objections with something being put down they tend to say it there if there's something I feel needs to be put down that they are kind of not feeling it we talk about why they're apprehensive about having that down in writing and what they think might be the potential outcome the when we do the assessment I do the same thing after I complete my assessment I tell them anything I write down you have the right to read because they do whether I like it or not is irrelevant they have the right to read their their clinical chart so I make it make sure that they know from the very beginning you know I'm not writing down anything scary or or whatever because a lot of times people who either haven't been to counseling before or may have had a bad experience may feel like you're writing down something that is unflattering to them so making sure that they feel comfortable with what's going on they see what we're putting down they see how we come to our diagnosis you know I help explain the process of you know how how did we arrive at this diagnosis of depression well because we talked about these symptoms so I like I like my clients to be fully aware of what's in their chart and why I'm making the recommendations I'm making because then it doesn't come back as them feeling like I was doing something underhanded or behind their back that's a really long non-answer to what do you exactly put in the chart versus worrying about a lawsuit and aside from saying in particular cases where you think it could become very litigious contact an attorney stick to the facts be objective as possible and you know you're going to be in much less murky water than if you start putting all kinds of interpretations in your chart what are other people's feelings on on that I've also heard although you're not supposed to do it I've heard of clinicians keeping basically two sets of books one with their subjective interpretations and another with their objective the other thing to remember is in most states progress notes need to be requested separately they're not actually part of the clinical record so make sure that when you're releasing information you know whether or not you have to release the progress notes in addition to the assessment data and other things but anyway back to y'all what are your feelings on cautious noting and again I like having them involved even if I don't think whatever case it is is going to be litigious because I find that it's empowering to them they learn more effectively how to set and follow through with goals and things like that and they know what's going on so it doesn't seem like I'm you know magically doing something and they're feeling better they're realizing their part in it the other reason I do notes with my clients is it keeps me on task because I really hate doing notes I'll be honest you know they have to be done but it's definitely helpful in a lot of different ways again you want to look at your state statutes for how long you have to keep records most states it's somewhere between five and seven years from the time of their termination from from the program so but again each state actually regulates how long you have to maintain records and I agree getting the clients buy-in in the treatment really helps them follow through and the more involved they can feel in the process the more likely they are to keep the momentum going has been my experience if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube if you want to attend and participate in our live webinars with Dr. Snipes you can subscribe at HGTBS colon slash slash all CE use dot com slash counselor toolbox this episode has been brought to you in part by all CE use dot com providing 24 seven multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 you can use coupon code counselor toolbox to get 20% off of your current order if you're a podcast listener especially on an Apple device it would be extremely helpful if you would review counselor toolbox to do this on your Apple device go to the podcast app search for counselor toolbox select the icon for the podcast tap the reviews tab in the middle you should then see an option to click write a review we love to seek five star reviews so if 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