Thursday, October 30, 2008

Confidentiality Issues Regarding the Treatment of Minors in Wisconsin

At the onset of any professional counseling relationship, it is imperative that the counselor obtain informed consent, by meeting with both the minor and her parents in order to inform them of the intentions of and possible outcomes of the service, explaining the importance that he or she places on confidentiality and also to specify the times in which a counselor must breach this, i.e. harm to self or others, sexual relations, abuse, and suicide. Counselors, who practice within the state of Wisconsin, are considered “mandated reporters” and are therefore governed by laws that pertain to the abuse or neglect of a minor. Wisconsin Statute §48.981(2), states that a professional “having reasonable cause to suspect that a child seen in the course of professional duties has been abused or neglected or having reason to believe that a child seen in the course of professional duties has been threatened with abuse or neglect and that abuse or neglect of the child will occur.”

Additionally, the state of Wisconsin finds that children under the age of 16 years of age, are unable to consent to activities of the sexual nature, and those who engage in a child in such activities will receive a felony conviction, (Wis. Stat. §948.02(1), (2)), therefore, any reports of such activities, regardless of implied consent must be reported to the health and human services department in their county. This requirement directly conflicts with the counselor’s ethical requirements, whereas ACA (2005) code B.1.c. finds that “Counselors do not share confidential information without client consent or without sound legal or ethical justification,” and also in code B.2.a. which states “the general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients of identified others from serious and foreseeable harm or when legal requirement demand that confidential information must be revealed.” This would then imply that a counselor is required to follow the laws in her state or county first, being that of a mandated reporter trumps the client’s right to confidentiality.

In situations where the information discloses does not include the sexual activity of, abuse and/or neglect to, or an intention of harm, issues of confidentiality related to minors, can mirror that of adults. Wisconsin Statute §118.126(1) states that a counselor “who engages in alcohol or other drug abuse program activities shall keep confidential information” that had been disclosed by a minor client during therapy sessions. And finally, in cases where a minor discloses their intent to commit suicide, Wisconsin law protects a counselor’s decision to breech confidentiality in finding §118.295 one “who, in good faith attempts to prevent suicide by a pupil is immune from civil liability for his or her acts or omissions in respect to the suicide or attempted suicide.” While, the law does not state that one must disclose these intentions, it does give permission for this disclosure.

Of additional concern, when working with minor children is the issue of parental disclosure. According to Remley and Herlihy (2001, p.103), “counselors have an ethical obligation of privacy to minor clients, and a legal obligation to the parents or legal guardians of those same minor clients to keep their children safe.” Unfortunately however, Wisconsin laws find that minor clients do not possess the ability to consent to services, or have the mentally capacity to make educated decisions regarding counseling services or to understand the rights and/or limitations of confidentiality, (Davis & Mickelson, 1994). As result, Remley and Herlihy (2001) suggest that the minors are afforded no privacy or disclosure rights from their parents and/or guardians who are legally responsible for them. Conversely they find that “a child, regardless of age, has an ethical right to privacy and confidentiality in the counseling relationship” (p. 176).

As a counselor in private practice, based on ACA (2005) code B.2.a., one does not necessarily have a legal obligation to inform a minor client’s parents and/or guardians of any situation in which the client is not in immediate danger. Many counselors will however struggle with the term “danger” finding the term in-and-of itself is subjective. What is the definition of foreseeable harm? Would statutory rape be considered harm? And while the law implies that a minor does not have the capacity to make informed decisions about their care, Remley and Herlihy (2001) find that parents or guardians “probably have a legal right to know the content of counseling sessions with their children,” (p. 177). Given this information, one could conclude that in cases that did not involve abuse, neglect, or sexual activity in a minor child under the age of 16, that the counselor may use their professional judgment in deciding which information, if any, should be disclosed. In the best case scenario, the counselor would work with the minor client in devising a plan to jointly inform or discuss the relevant and necessary information to the parent, past this it would seems that disclosure is a subjective.
Stephanie Lowrance-Henckel

References
American Counseling Association (2005). Code of Ethics. Alexandria, VA

Remley, T. P., & Herlihy, B. (2001).
Ethical, legal, and professional issues in
counseling. Upper Saddle River, NJ: Merrill Prentice Hall.

Wisconsin Statutes §48.981(1) and §48.981(2). (1999-2001). Wisconsin Legislature. Retrieved on October 25, 2008 from http://nxt.legis.state.wi.us/nxt/gateway.dll?f=templates&fn=default.htm&d=stats&jd=Wisconsin%20Statute%20§48.981(2)

Wisconsin Statute §118.295. (1999-2001). Wisconsin Legislature. Retrieved on October 25, 2008 from http://nxt.legis.state.wi.us/nxt/gateway.dll?f=templates&fn=default.htm&d=stats&jd=Wisconsin%20Statute%20§48.981(2)

Wisconsin Statute §118.126. (1999-2001). Wisconsin Legislature. Retrieved on October 25, 2008 from http://nxt.legis.state.wi.us/nxt/gateway.dll?f=templates&fn=default.htm&d=stats&jd=Wisconsin%20Statute%20§48.981(2)

One Flew Over the Cuckoo's Nest - An analysis

Just recently this writer had the opportunity to experience the 1975 movie, One Flew Over the Cockoo's Nest. How in all her years of interest in the field of psychology has she missed this film, is quite a mystery. This writer was absolutely shocked and horrified as she watched this movie, “One flew over the cuckoo’s nest” unfold. Although she had heard rumors of these mental institutions and the stereotypes that had carried over all these years, she failed to realize the scope of injustice that was done onto the patients. While analyzing this movie, the writer found herself feverishly writing notes regarding the ethical, therapeutic, and humanistic violations that were depicted, and now as she sits to write, finds it difficult to limit herself to discussing only a few.

The main perpetrator of the movie was nurse Ratched. Although we are unclear of her qualifications, one would presume that she were a psychiatric nurse practioner. And while this title would suppose that she had received education and training pertinent to this field, her title should be used loosely.. as she did not deserve to hold the authority that she did. If one were to critique her leadership abilities and place a style to it, it would be leader-directed or leader-oriented. And while she would be then called to lead a group, she failed to understand each client’s needs and structure group focus to meet those needs, (Lantz, 2001). In the leader-directed approach, she would have been responsible for providing information and educating the clients on the chosen topic. Because these clients appear to be mentally functioning at a child-like level, structured group activities should also be intermingled with lecture, as attentions can easily wane, and hands-on activities has been shown to be tremendously effective at keeping the client focused on the topic, (Jacobs, Masson & Harvill, 2009) and broadening their depth of understanding. While the goal in working with groups is to maintain a singular focus, it is sometimes necessary to shift if as a leader, one recognizes a disconnect or the client’s inability to attend to the topic. Continued attempts to persevere will surely end in the client becoming disruptive, resentful, and tuning out to the topic, however one must impress that the change in topic remain therapeutic and healthy for the clients as a whole, nothing like that depicted in the movie.

If one further attempted to analyze the group dynamic and the supposed therapeutic nature of this group, isolated from the facilitator, they would also find it quite unhealthy. In an effort to analyze this the characteristics of effective group therapy, Yalom (1995) finds a number of factors, which can substantially contribute to the group process and success. These factors can include; instillation of hope, universality, imparting information, altruism, the corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. In the three scenes that the viewer was privy too, not one time did there appear to be a single focus or topic, instead the discussion was based around the facilitator’s choice for belittlement of the day and the group also served as a arena for the clients to air their grievances about treatment, and each other without being heard or redirected. It appeared that no group format existed, besides the time allotment, and no rules were presented or adhered to. At one point, nurse Ratched referred to the group as being therapeutic, but even to the most unskilled eye, this was a ridiculous assumption. No therapy was being conducted in these groups, no understanding of disorder, treatment, healthy living, self-esteem building, no realizations, and even worse, the clients appeared become increasingly distraught throughout group, then were left hanging without the opportunity to process. These clients were brought together based on their ability to attend to the group, but never really pre-screened for compatibility, i.e. level of disorder, commonality between issues and ailments, in short, this created chaos. Due to the dynamics of the group, coupled with the dictator-like, uncompassionate, judgmental leader, these clients failed to progress. And while all of these clients arrived to the facility wounded, fearful, lonely, and ashamed, they may have ended up worse than when they initially presented for treatment. This writer believes that therapeutic groups can only begin to have individual progress when the participant him or herself feels as though they are safe, accepted, understood, and can see the “light” or hope for the future, but none of these feelings were facilitated for the clients in this ward.

Above all other problems, is that of ethics. The American Counseling Association, realizing that there were great disparities in treatment of mentally ill clients, created their first code of ethics in 1952, (Code of Ethics, 2005). While we then know that there was such a guideline for therapists, we must then assume that the practioners depicted in the movie were not taught such principles during their training, nor could there have been any consequences for failing to adhere to these rules. If in fact, these guidelines had been taught, reviewed, and therapists been penalized for not implementing them, almost all of the issues could have been avoided.

If this writer were called to evaluate and consult for this facility, she would have found herself outraged on the first day, maybe even the first hour. Her recommendations would have been simple and drastic. All employees would have been placed on “leave” until they could receive their own psychiatric evaluations, and if found competent, received proper training. All Electro-Convulsive therapies would have been halted, as these were preformed for the wrong purpose, by unqualified staff, and the practice of lobotomizing clients would have been terminated. A competent and skill staff would be temporarily placed within the facility and all clients would have been re-evaluated and placed in wards according to their disorder, competency level, and need. The practice of medicating, or should we say, sedating all patients into compliance would have gradually waned (for fear of withdrawal symptoms), during which time the clients would be re-assessed for proper medications. The new group leaders would be well trained in group dynamics, and new groups would be formed. These groups would follow a model outlined by Yalom (1995) and others, which would allow for a group purpose, rules, and phases, to allow for proper processing. And the ACA code of ethics (2005) would be the law of the facility, the credo, “Do no harm” would be repeatedly drilled into the employees heads, so that no one lost sight of this again! Only after these changes were made would the clients actually be treated, instead of becoming worse, and even some may one day be able to leave the facility as functioning members of society.
Stephanie Lowrance-Henckel

References
Code of Ethics. (2005). American Counseling Association. Washington, DC.
Jacobs, E., Masson, R. & Harvill, R. (2009). Group counseling: Strategies and skills (6th ed.). ThomsonBrooks/Cole. Belmont, CA.
Lantz, J. (2001). Play time: An examination of play intervention strategies for children with autism spectrum disorders. The Reporter, 6(3), 1-7, 24.
One flew over the cuckoo’s nest. (1975). Milos Forman (Director). Fantasy Films, Oregon. Video recording.
Yalom, I. (1995). The theory and practice of group psychotherapy (4th ed.). BasicBooks. New York, NY.

Tuesday, October 14, 2008

Model of Group Therapy: Essential when the client is a child

Leading a group can be a very daunting and intense experience. To make matters worse, many leaders are either unprepared, under skilled, or under-educated about group dynamics and it’s processes. While there are numerous resources outlining these conditions for work with adults, very little materials cover work with children or adolescents, especially when working with child victims of abuse. The purpose of this article is to provide a brief and basic summary of an appropriate group model for use when working with abused children within an open enrollment, agency setting.

It is imperative that one understands that as a group leader of children participants, he or she must use the leader-directed or oriented approach. Jacobs, Masson and Harvill (2009) suggest that children’s group leaders be prepared “to take on more responsibility for the group than in a group composed of adults,” (p. 399) as children will not usually come to group ready to discuss a particular topic nor will they be inclined to stay on topic if not directed. Additionally, a substantial portion of any children’s group will include an education component, whether that be regarding the importance of self-esteem, anger management, or general safety planning to reduce the likelihood that a child be further victimized, it will be the leader’s responsibility to present this information. It is therefore necessary that this leader understand each child’s needs and structure group focus to meet those needs, (Lantz, 2001).

As with any other type of group, it is important that each session be structured with a beginning, middle, and closing phase. When working with child clients, particularly in an open enrollment type group, it is necessary to formally engage the children in the beginning stage. Introducing new students, reiterating the group purpose, and acknowledging the commonality that all the participants share will aide in the effectiveness of the group in two ways; (1) this will allow the “new” child to begin feeling comfortable, safe, and sense of belonging, and (2) reinforce the effectiveness, commonality, and focus to the “seasoned” participants. This phase should be no longer than 10 minutes, otherwise the leader risks the chance that the children will become bored and thus engaging in alternative activities that will deter from the order of the group.

The middle phase will contain the depth of the discussion and topic for the day. In the leader-directed approach, he or she will be responsible for providing information and educating the children on the chosen topic. Structured group activities should also be intermingled with lecture, as attentions can easily wane. Hands-on activities, will enhance the the group as they have been shown to be tremendously effective at keeping the child client focused on the topic, (Jacobs, Masson & Harvill, 2009) and broadening their depth of understanding. While the goal in working with children groups is to maintain a singular focus, it is sometimes necessary to shift if, as a leader, one recognizes a disconnect or a child’s inability to attend to the topic. Continued attempts to persevere will surely end in the children becoming disruptive, resentful, and tuning out to the topic. Again, as a children’s group leader, it is necessary to be observant and gain an understanding of each participants needs in order to remain beneficial to the clients.

The final phase is just as important as it’s counterparts. This phase allows for the child client to process those feelings that surfaced as result of group, gain a sense of closure, and participate in the ending rituals of the group. The final phase can include several techniques such as: relaxation breathing, songs, or a movement activity. Often times, leaders will impart food into their final phase. Kaduson (2006) maintains that food is beneficial in two ways, “it provides an effective form of tangible nurturance,” (p.251) thus reinforcing that group is a safe and caring place, and “second, snack time parallels a family meal in ways that often facilitate treatment….. just as shared meals help strengthen bonds within functional families, snack times provide the group members with opportunities to process issues, talk through problems, share feelings, and resolve conflicts together,” (p. 251).Which ever method is used, is important to remember that the “ritual” of this phase is important to facilitate the continued growth of the group, (Kaduson, 2006) and that it should be employed at every session, (Jacobs, Masson & Harvill, 2009).

It is crucial that one does not undervalue their work as a group leader or the value that group therapy can provide for the child participants. Authors such as Shechtman (2004), in addition to many other professionals, agree that group therapy and interventions instilled therein are quite effective when working with children. And “for some children, groups can be much better than individual counseling because groups allow children a place to learn and practice new skills,” (Jacobs, Masson & Harvill, 397). While this article serves to provide the reader with only a brief summary of a group model used with children, the phases and formation of rituals should be considered quite heavily when planning such groups. Kaduson (2006) finds that an emphasis needs to be placed on predictability when working with children, as this experience leads to a naturally occurring sense of safety and order within the group. Likewise, “beginning and ending rituals contribute to the establishment of trust and security, as anxiety is reduced when children can anticipate what will happen,” (p. 250).
Stephanie Henckel
References
Jacobs, E., Masson, R. & Harvill, R. (2009). Group counseling; Strategies and skills (6th ed.). ThomsonBrooks/Cole. Belmont, CA.
Kaduson, H. (2006). Short-term play therapy for children (2nd ed.). Guilford Publications, Inc. New York, NY.
Lantz, J. (2001). Play time: An examination of play intervention strategies for children with autism spectrum disorders. The Reporter, 6(3), 1-7, 24.
Shechtman, Z. (2004). Group counseling/psychotherapy with children. The Group Worker, 32(3), 7-9.

Monday, October 13, 2008

Reality therapy and the Asian American Client

A study conducted by Tsai-Chae and Nagata (2008) found that “immigrant families from traditional Asian backgrounds can experience greater family dysfunction than other ethnic minority groups,” (p.205). Additionally, the majority of these conflicts arise during adulthood and in comparison to European American adolescents the “levels of family conflict were significantly higher among Asian American college students,” (p.305). These intergenerational conflicts, which arise during adulthood, have been positively correlated with psychological problems such as anxiety and depression “and Asian American students who enter counseling frequently attribute their psychological distress to relationships with their parents,” (p.305). While the counselor may be initially concerned about an Asian client’s reluctance to “open-up” and discuss the root of his or her issues, it is important to note that, in general, Asians Americans tend to under utilize mental health services and “recent reports indicate that less than 6% of Asian Americans with a psychological problem sought assistance,” (Hsu & Alden, 315). Of those Asian Americans who do seek the assistance of a mental health professional tend to do so only after there is a persistent and excessive somatic or behavior symptom of their emotional distress (Hsu & Alden, 2008). Asian clients often express a desire to honor their parents and a fear of causing them shame, this value is founded in the Asian belief that family members share a single sense of identity and responsibility to each other, therefore the client’s behaviors are not just representative of themselves but of their family as a whole. In acknowledging this value, one could assume that a client’s hesitance to talk with the therapist, would be founded in the belief that “the burden of the stigma of mental illness not only falls on the afflicted individual but also on all family members,” (p.318). Therefore, a concern of bringing shame upon his or her family may be the basis for the client’s reluctance to admit to mental health problems.

Reality therapy, an approach founded by William Glasser, similar to that of Rational Emotive Behavioral Therapies (REBT) and has been shown effective when working with diverse clients. “Reality therapy explores the client’s values and behavioral choices, exposing inconsistencies and enforcing responsibility for those choices,” (Okun & Kantrowitz, 138). Those who subscribe to the Reality approach believe that, as humans, we alone, are responsible for our actions. Reality therapist’s propose that “human beings are motivated to change (1) when they determine that their current behavior is not getting them what they want and (2) when they believe they can choose other behaviors that will get them closer to what they want,” (Corey & Corey, 140). The goal of treatment utilizing this approach is to assist the client in satisfying their basic needs, i.e. “survival, love and belonging, power, freedom, and fun,” (p.140) thereby directing change to those behaviors which inhibit that fulfillment of these needs. Regardless of which method one may chose, the overall goal is to treat the client’s emotional and physical disturbances. Reality therapy would focus on negative effects of the client’s current choice of actions and assist him or her in finding more appropriative constructive behaviors which would encourage a balance between their own needs and values and that of their family.

Currently this writer finds herself most aligned herself with Reality therapy. As she has explored this method, and has read descriptions depicting Reality therapy in practice, and finds great benefit in this approach's belief that; to get better or be "treated" one must recognize and change those behaviors that are self-defeating. Often times, she herself has heard the common-sense voice of Dr. Phil ringing through her head, “Is it working for you?” and finds great value in this approach. When working with guests who appear on his show experiencing emotional distress at the way events are playing out in their lives, Dr. Phil inquires about the action they have taken to alter these events. If he believes that their actions are self-defeating or fail to promote the positive response the guest desires, he simply suggests that their approach is not working and informs that they must change how they have been doing things, if they are to expect a different outcome. -“The definition of insanity – doing the same thing over and over, expecting a different result.”

Stephanie Henckel

References

Corey, M. S. & Corey, G. (2007). Becoming a helper (5th ed.). Thomson Brooks/Cole. Belmont, CA.

Hsu, L. & Alden, L. (2008). Cultural influences on willingness to seek treatment for social anxiety in Chinese- and European-heritage students. Cultural Diversity and Ethnic Minority Psychology, 14 (3), 215-223.

Okun, B. F. & Kantrowitz, R. E. (2008). Effective helping: Interviewing and counseling techniques (7th ed.) Thomson Brooks/Cole. Belmont, CA.

Tsai-Chae, A.H. & Nagat, D.K. (2008). Asian values and perceptions of intergenerational family conflict among Asian American students. Cultural Diversity and Ethnic Minority Psychology, 14(3), 205-214.