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C H A P T E R 11

Efficacy of Treatment

Michelle: Hi, Lynn. Do you have a minute?

Lynn: Sure, Michelle. What’s up?

Michelle: I’ve been working with this girl, Maria, and we have a real good working relationship, but I just don’t feel like I have a true grasp of what is going on or that I am approaching this situation the best way. I explained this to Maria, and she has given me written permission to speak with you about the case. I know you are really busy, but I was hoping that you could provide some supervision around this case to see if you feel like I’m on the right track and using the best approach.

W hile our counselor, Ms. Wicks (Michelle), is certainly skilled and trained professionally, her real interest and concern for her client and her own self-awareness of the limits of her expertise have

led her to seek consultation from a colleague. Approaching helping with the essential training and experience is an ethical must. However, beyond this initial training, ongoing professional development, consultation, and supervi- sion are the hallmark of the ethical professional.

The ethical responsibility to be competent extends beyond the basic credentialing of a helper and includes the helper’s ability to employ treat- ment strategies that are efficacious. It is these issues of treatment efficacy and helper competency that serve as the focus for the current chapter.

Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:51:29.

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The chapter will review the ethics and legality surrounding the issue of competent practice and efficacy of treatment. The value of professional train- ing, action research, and referral as elements of competent practice will be highlighted.

After reading this chapter you should be able to do the following:

• Describe what is meant by the term competence. • Discuss the role of continuing education, ongoing supervision, and con-

sultation in the continuous development of professional competence.

• Describe the value of approaching practice from a reflective, action research orientation.

• Discuss the conditions under which referral would appear to be the most efficacious treatment decision.

• Describe legal considerations and concerns in relation to the issue of helper competence, standard of care, and treatment efficacy.

● OBJECTIVES

● PRACTICING WITHIN THE REALM OF COMPETENCE

The ethical professional is called upon to accept responsibilities and employ- ment on the basis of competence and professional qualification. Table 11.1 provides the position taken by a select group of professional associations on the issue of professional practice and competency. What should be evident by reviewing Table 11.1 is that each of these organizations supports the notion that one should not engage in practices that require skills beyond those possessed. To be ethical as a helper requires that competency be developed and maintained and that the helper’s competence level be repre- sented accurately to clients, employers, and the general public.

Competence

Being competent means that the helper has the knowledge, skills, and abilities needed to perform those tasks relevant to that profession. To sug- gest one is competent implies that the individual is capable of performing a minimum quality of service that is within the limits of his or her training, experience, and practice, as defined in professional standards or regulatory statutes.

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Chapter 11. Efficacy of Treatment–●–269

Table 11.1 Ethical Codes Addressing Helper Competence

Professional Organization Ethical Principle/Standards

American Counseling Association (2014)

C.2.a. Boundaries of competence

Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Whereas multicultural counseling competency is required across all counseling specialties, counselors gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population.

American Psychological Association (2010)

2.01. 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.

American Association for Marriage and Family Therapy (2015)

3.10.

Marriage and family therapists do not diagnose, treat, or advise on problems outside the recognized boundaries of their competencies.

National Association of Social Workers (2008)

4.01. Competence

c. Social workers should base practice on recognized knowledge, including empirically based knowledge, relevant to social work and social work ethics.

Ethical principle: Social workers practice within their areas of competence and develop and enhance their professional expertise. Social workers continually strive to increase their professional knowledge and skills and to apply them in practice. Social workers should aspire to contribute to the knowledge base of the profession.

1.04. Competence

a. Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

b. Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques.

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Competence is defined in relative terms; that is, rather than having one clear, objective standard against which to judge a professional’s level of performance as competent or incompetent, competence is most often defined using the conduct of others within the profession as the compara- tive standard. Thus, one might ask, what would a reasonable person do in a similar situation?

● PROFESSIONAL DEVELOPMENT: KNOWING THE STATE OF THE PROFESSION

Competence can be developed from formal training as might be found in graduate training or training for certification and licensure. Further, one’s own ongoing continuing education, professional reflective practice, and supervision may serve as additional resources for developing and maintain- ing competence.

Formal Training

Formal training occurs both at the undergraduate and graduate levels of study. Foundations of general knowledge of helping theory and skills along with research supporting intervention strategies may be acquired through undergraduate and graduate course work. However, in addition to these cog- nates, the competent practitioner must have guided practice in the applica- tion of this knowledge. In many disciplines (e.g., psychology), the doctorate along with supervised field and intern experiences is considered essential to competent independent practice.

For most of the helping professions, professional organizations and/ or certifying and licensing bodies have identified both aspirational levels and mandatory levels of training as a way of defining competence. Each of these levels of governance monitor the development and application of professional practice. Colleges and universities often offer programs of training that have been shaped by the professional standards under the review of professional accrediting organizations. Professional accrediting bodies (e.g., American Psychological Association, Council for the Accredi- tation of Counseling and Related Educational Programs [CACREP]) qualify educational programs as meeting standards beyond those demanded for col- leges or universities to offer degrees and certify that these programs meet high professional standards, thus establishing the foundation for ethical practice. Beyond these school-based programs, professional organizations

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(e.g., American School Counseling Association, American Rehabilitation Counseling Association, Academy of Certified Social Workers) often develop aspirational codes of ethics, which while not having any internal mandatory enforcement mechanism, call their members to perform at the highest level of professional practice.

Beyond the professional organization level, the professional regulatory bodies at the state and national level promulgate and enforce standards of practice through the establishment of certification and licensure standards. Often these requirements exceed those demanded for entrance into the pro- fession, requiring additional post degree experience and supervision. The definition of minimum professional training for entry-level helpers as well as the mandate to remain up-to-date on the state of the profession through continuing education varies from state to state. It is essential for the ethical helper to be knowledgeable about these standards (see Exercise 11.1).

Being an ethical, competent practitioner requires not only a basic level of initial training but also the development and maintenance of this knowl- edge and these skills via continuous professional growth. The ethical helper continually strives for increased competence. The ethical helper strives to increase his or her competence by continuing to develop his or her skills and understanding of the helping process.

Exercise 11.1

Licensing and Certification Requirements

Directions: Since the requirements defining minimum requirements for competent practice vary from profession to profession and in many instances from state to state, it is helpful for you to be aware of the specific requirements for entrance into your particular field of practice.

Step 1: Identify two arenas for professional practice (e.g., school counselor, psychologist, marriage counselor, clinical social worker, etc.).

Step 2: Identify two states, one in which you intend to practice and a neighboring state.

Step 3: Contact each state’s department or bureau of professional license and practice.

Step 4: Complete the following grid. (Continued)

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Practice Specialty 1 Practice Specialty 2

State Home State

Neighboring State

Home State

Neighboring State

Minimum Education (bachelor’s, master’s, master’s + doctorate)

Supervised Experience (internship, practice, etc.)

Post Degree Requirements (course work, field experience, etc.)

Other Requirements

(Continued)

Continuing Education

All the codes of conduct call for practitioners to be current with emerg- ing knowledge relevant to their professions (see Table 11.2). It is incumbent upon the ethical practitioner to upgrade knowledge and skill by participat- ing in continuing education experiences. Continuing education may be in the form of trainings through a professional conference or additional course work at the local university or courses taught through qualified associations and organizations.

While the call for ongoing education and professional development is clear, the specifics are still lacking. Does this suggest a certain number of courses? Credits? Hours of supervision? Many organizations and state licensing and certifying bodies require that a number of continuing edu- cation hours be completed within a number of years. For example, in Pennsylvania, all licensed marriage and family therapists seeking renewal of their licenses are directed to gain 30 hours of continuing education every

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Table 11.2 Maintaining Professional Development

Professional Ethical Standards Statement on Professional Development

American Association for Marriage and Family Therapy (2015)

3.1.

Marriage and family therapists pursue knowledge of new developments and maintain their competence in marriage and family therapy through education, training, and/or supervised experience.

American Counseling Association (2014)

C.2.f.

Counselors recognize the need for continuing education to acquire and maintain a reasonable level of awareness of current scientific and professional information in their fields of activity. Counselors maintain their competence in the skills they use, are open to new procedures, and remain informed regarding best practices for working with diverse populations.

American Psychological Association (2010)

2.03. Maintaining competence psychologists undertake ongoing efforts to develop and maintain their competence.

National Association of Social Workers (2008)

4.0.l.b.

Social workers should strive to become and remain proficient in professional practice and the performance of professional functions. Social workers should critically examine, and keep current with, emerging knowledge relevant to social work. Social workers should routinely review the professional literature and participate in continuing education relevant to social work practice and social work ethics.

two years (http://pamft.com/for-professionals/licensure/faq/). Similarly, the State Board of Licensing for Psychologists in Pennsylvania requires psychologists to complete 30 hours of approved continuing education every two years in order to maintain and/or renew their licenses. While the spe- cific requirements vary across professions (e.g., marriage counselor, school psychologists, clinical social worker) and from state to state, similar demand for maintaining competence is built into all certification and licensing requirements. It is important for each practitioner to be aware of the stan- dards set by his or her own professional organization or those required for relicensing or recertification within the state where they intend to practice.

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Supervision and Consultation

Practicing within the realm of competence starts with a practitioner operating within the scope of practice. Practitioners are ethically bound to restrict their professional activities to the professions and specialties for which they have been trained and supervised. When required, they must possess the appropriate certification and licensure. Practicing within the realm of competence also means knowing when it is essential to consult and/or refer to another professional who has more experience and training with this particular type of client and or problem.

The use of peer consultation, in which specific concerns can be shared with an experienced colleague, is a valuable means for maintaining compe- tence. Peer consultation may be useful in enhancing the clinical care of the client as well as acting as a risk management tool for the helper by provid- ing trusted resources (Gottlieb & Younggren, 2009). Peer consultation can provide mutual support for problematic cases. However, when consulting with colleagues regarding a client, the ethical practitioner needs to balance the need for his or her own continued support with the client’s right to maintain confidentiality. The American Psychological Association’s (APA) ethical standards, for example, state:

When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identifi- cation of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of consultation. (APA, 2010, 4.06)

Even with this sensitivity to the requirements of confidentiality, the ethi- cal helper can employ a peer consult to formulate the problem, review the decisions made, and tap a different point of view on the process. Often a colleague with more experience can provide some clarity about the helping process and may even assist the practitioner to develop additional insights or adjustments in the treatment process.

Consulting with a professional peer not only provides the helper a valuable resource for expanding his or her knowledge and skill but also can also serve as a valuable check and balance for the helper when the boundaries of competence may be exceeded. This is especially true when the helper’s own objectivity may be blurred (see Chapter 10). Under these

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conditions, the peer consultation can provide a mechanism for examining the ethical and professional issues involved (Gottlieb & Younggren, 2009).

For those working within certain clinical settings, formal peer review may be incorporated as a way of maintaining professional competence and standards of care. For those serving in an independent practice, it would be valuable to develop a network of colleagues who can continue to serve as peer consultants.

THE STANDARD OF CARE: APPROPRIATE TREATMENT ●

Most malpractice cases turn on the question of negligence (Bennett, Bryant, VandenBos, & Greenwood, 1990). Negligence implies that the practitioner failed to meet the relevant standard of care. According to Bennett and col- leagues (1990), the question of negligence will be determined by the debate over the clinical connectedness and efficacy of the treatment that was given, along with the practitioner’s judgment in choosing it (p. 33).

While there is no single prescribed way to conduct “helping,” ethi- cal guidelines establish some standards of care that must be followed. For example, sexual intimacies with clients are prohibited. Further, innovative therapy involving physical contact with clients can be the basis for malprac- tice suits, particularly when the contact is extreme (e.g., hitting, choking). While these are extreme examples that most mental health providers will not encounter, failure to properly administer and interpret tests and inven- tories, failure to warn to take appropriate steps in the face of homicide and suicide, and failure to employ appropriate methods and forms of treatment may be areas in which helpers are more likely to fall short of recognized standards of care, failing to provide appropriate treatment.

Defining an Appropriate Treatment

Standards of practice have not specifically been identified. There are no preordained directives for what must be done under each condition of helping. The standard of care and the definition of appropriate treatment are typically determined by comparing the practitioner’s performance with that of other professionals in the same community with comparable training and experience.

There is an evolving sense of what should prevail, and it is the standard of what a reasonable and prudent practitioner may do in situations like this that sets the standard of care (see Exercise 11.2).

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Exercise 11.2

Standard of Care: A Reasonable, Prudent Response

Directions: Below you will find two clinical scenarios. Read each situa- tion and contact two mental health providers in your local community and ask them what they would do in this situation.

Situation 1: You are treating an individual diagnosed with AIDS. This individual has informed you that he is in and has been in a long-term relationship. The client also has informed you of the name of his partner, with whom he lives. In your most recent session, your client informs you that not only is he engaging in unprotected sex with his lover but that he has not informed his lover that he has AIDS. What do you do? Do you inform the lover?

Situation 2: You have been seeing a couple for marriage counseling. You receive a subpoena for your records on the case from one partner’s lawyer. What do you do? Do you respond to the subpoena? How?

Reflections:

● Did the two practitioners essentially agree on the steps to be taken?

● Did their responses seem to be in line with what you have read about confidentiality, duty to warn, informed consent, and so forth?

● Share your findings with a classmate/colleague who may have performed the exercise. Does there seem to be consistency in practitioner response that could be interpreted as a definition of standard of care?

Share your findings with your classmates or colleagues.

Employing Effective Treatments

Beyond a generic standard of what a reasonable and prudent practitioner may do, attention has been drawn to the importance of employing tried-and- true techniques and strategies of intervention. A number of professionals and professional organizations have called for use of effective treatments, as have consumer groups. The ACA Code of Ethics, for example, notes, “Counselors have a responsibility to the public to engage in counseling practices that are based on rigorous research methodologies” (ACA, 2014,

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Introduction Section C). Or even more specifically, “When providing ser- vices, counselors use techniques/procedures/modalities that are grounded in theory and/or have an empirical or scientific foundation” (ACA, 2014, Principle C.7.a). A similar directive is found within in the National Associa- tion of Social Workers’ (NASW) Code of Ethics, which notes, “Social workers should base practice on recognized knowledge, including empirically based knowledge, relevant to social work and social work ethics” (NASW, 2008. Principle 4.01.c). Thus, it is firmly rooted in our codes of ethics that coun- selors use techniques that are empirically based. It is clear that the ethical helper needs to be aware of the current research on treatment effectiveness and employ these strategies when and where appropriate.

Defining Efficacious

Providing the most effective treatment available requires professionals to keep current on the research on treatment effectiveness for their particu- lar client populations. In line with this need to identify and employ effective treatment strategies, the Task Force on Promotion and Dissemination of Psychological Procedures (1995) from the division of clinical psychology within the APA, developed criteria for determining whether a treatment should be considered empirically valid. The task force also established a list of inter- ventions that have been “well established” and a list that are “probably effica- cious,” citing the literature that supports this claim (Chambless et al. 1998).

A review of those treatments that prove effective suggest that they share the following characteristics: These interventions are targeted to spe- cific problems, incorporate continuous monitoring and assessment, involve client skill development, and are generally brief, requiring 20 or fewer ses- sions (O’Donohue, Buchanan, & Fisher, 2000).

As the professions and the research identify specific strategies with dem- onstrated effectiveness, these interventions become the standard of care. As such, it is essential for the ethical practitioner to not only be aware of this research and these techniques but to develop the competency required for the ethical application of these strategies.

Managed Care: Compounding the Standard of Care Issue

The issue of treatment efficacy is of special consideration when a prac- titioner is operating within a managed care situation (Cohen, Marecek, & Gillham, 2006). With managed care pushing for brief, more cost-effective

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forms of treatment, the ethical practitioner must be able to identify for whom these services are appropriate and which form of service is required. Discerning for whom brief therapy is appropriate and advocating for those clients for whom such an approach may not be appropriate becomes an essential role of the ethical, competent practitioner operating within a managed care environment. Further, competence to perform short-term models of treatment, when appropriate, requires that the practitioner be prepared and able to focus on achievable, specific treatment goals and to be active and more directive in conducting the treatment. Short-term models are not simply long-term therapy models condensed in time. Utilization of these short-term models requires the ethical practitioner to possess unique understanding and skills. Thus, the ethical practitioner will not only know for whom such treatment is appropriate but will also have been trained in this approach. If the practitioner is not trained in the area that is specified, it is the responsibility of the practitioner to receive the appropriate training, at times before accepting an offer for employment (Daniels, 2001).

● EMPLOYING AN ACTION RESEARCH APPROACH TO PRACTICE

In areas for which there is not solid research to direct best practice or in which the standard of the profession is not clearly articulated, service needs to be predicated on theoretical and technical ideas that are held by a substan- tial portion of the profession. Thus, knowing the recognized models, theories, and schools of thought is as essential as having the ability to assess the validity and reliability of a particular strategy for one’s own practice. In speaking of psychology, for example, Chambless and colleagues (1996) noted:

Psychology is a science. Seeking to help those in need, clinical psychol- ogy draws its strength and uniqueness from the ethic of scientific valida- tion. Whatever interventions that mysticism, authority, commercialism, politics, custom, convenience, or carelessness might dictate, clinical psychologists focus on what works. They bear a fundamental ethical responsibility to use, where possible, interventions that work and to subject any intervention they use to scientific scrutiny [emphasis added]. (p. 10)

This last point suggests subjecting any intervention to scientific scru- tiny is a directive to all ethical practitioners and not just those interested in

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performing large empirical research. The ethical helper will approach his or her practice as a reflective professional, integrating research and practice.

In order to be effective in their practice, human service providers must blend the method and findings of research with the realities of their profes- sional practice. As practitioner-researchers, they will need not only to interact in the moment but also to reflect, inquire, and critique their own interac- tions. Further, for their observations to provide meaningful data and useful guidance, they must be systematic and valid. Action research methodology provides practitioners with the means of acquiring these valid, useful data and results in the development of effective strategies of professional practice.

Action Research Defined

As presented here, action research is applied research in which the researcher-investigator is also the practitioner (e.g., a counselor, psycho- therapist, social worker) attempting to use research as a methodology for identifying the “what” they do and for making decisions on doing it better. Action research provides practitioners with the method for viewing their professional decisions systematically and deciding on them rationally. It is the opportunity to blend theory with practice, becoming true practitioner- researchers. Action research has a circular nature (plan-act-observe-reflect and then start all over again), which supports a reflective practitioner and guides increased awareness of effectiveness.

Action Research: An Ethical Consideration

Viewed as a frame of mind, action research calls us to a continued inter- est in serving our constituencies better and providing increased accountabil- ity for our service. As such, action research is not simply a good idea, rather it becomes an ethical responsibility for monitoring the effectiveness of our practice and increasing the competency of our service. No one professional can guarantee success in each and every encounter or situation. However, ethical practitioners need to assess the degree to which their practices are both valid and effective. Action research provides a mechanism for monitor- ing the efficacy and adequacy of practice decisions and methods.

Table 11.3 provides a brief review of one model of action research that has application to the mental health professional. While presented as a linear set of steps to be taken, in practice it is a recurring, recycling process that continually takes shape in and gives shape to practice.

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Table 11.3 Steps in the Action Research Process

Step Description

1. Identification of the research question

Three types of questions seem to emerge. First, what are our practice decisions? Second, what specifically about our practice is effective? And finally, what can we do to enhance our effectiveness as practitioners?

2. Problem relevance, problem significance

The goal is to be able to answer questions such as, why study it? What do I expect will happen as a result of this investigation? How is the problem and the study significant to my practice?

3. Definitions The practitioner–action researcher needs to begin to more concretely identify and define the concepts, the constructs, the variables involved. When and where possible, the action researcher needs to define these by his or her actions or operations performed (i.e., operational definitions).

4. Review of related literature

Reviewing the professional literature for evidence of similar investigation may prove a valuable step to intervention planning.

5. Developing hypotheses

With action research, it should be remembered that these are truly “working hypotheses.” As data is collected and decisions are made, the hypotheses may be reshaped. In fact, true to the qualitative nature of the action research, new hypotheses can emerge from the data as the study progresses.

6. Outcome measures

If the action researcher seeks to increase his or her understanding of the operations of his or her professional practice or the impact of specific practice decisions, then measurement of those decisions and their impacts needs to take place. One should employ outcome assessment that measures change from multiple perspectives (i.e., the subject/client, the practitioner-researcher, and others) and through multiple approaches.

7. Methods: creating a design

As with any study, for our conclusions to be valid we must consider the use of an approach or a design that provides validity of data collection and interpretation.

8. Data collection The types of data collected and the method of collection will clearly be situation, researcher, and problem specific. But the information gathered needs to be as detailed and as informative as possible so that as an action researcher, you will know what is happening in ways that you previously did not know. The action researcher needs to remember that he or she is a practitioner as well as a researcher and that he or she has a professional responsibility for those involved. There are ethical considerations, especially those regarding informed consent, that need to be considered.

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Step Description

9. Data analysis At a minimum the data needs to be organized and grouped by themes, with trends and characteristics noted. When appropriate, visual presentation and descriptive and inferential statistics should also be employed.

10. Interpretation In reviewing the data, the action researcher needs to balance research significance with practical relevance. Having answered the question what happens if, the researcher now needs to answer questions such as these: What does knowing what happens if mean for my clients, my students, and for those whom I service? To me? To my professional decision-making? To my current practice decisions?

THE USE OF REFERRAL ●

The ethical helper provides only those services for which he or she is trained, experienced, and credentialed (e.g., certified or licensed). Compe- tence refers not only to the degree to which the professional possesses the knowledge, skills, and abilities required to perform the various tasks and procedures relevant to that profession but also to the ability to discern when it is appropriate to provide the services and when it is desirable to refer.

In the private confines of a helper’s office, however, where a practi- tioner is free from direct supervision or teacher scrutiny, it may be all too easy to be seduced into engaging in problem solving in areas for which one is ill prepared. Consider the following case of Mrs. Robinson (see Case Illustration 11.1).

Even if we assume the best intent on the part of Dr. Hansen, the truth of the matter is that he lacks the training and appropriate experience to work with Mrs. Robinson’s clinical depression. Further, his lack of experi- ence and training is more evidenced by his willingness to serve as both Mrs. Robinson’s therapist and marital counselor.

If one were to assume that Dr. Hansen was qualified to work with a depressed client, it might be easy to believe the transition from working with the distraught Mrs. Robinson to couple-marriage counseling was a logi- cal extension of the helping contract. However, suppose Dr. Hansen has not had the specialized training that may be required.

The American Association for Marriage and Family Therapy highlights the unique training necessary to be a clinical member, training that includes spe- cific graduate training in marriage and family therapy and two years of super- vised practice. Given the special training necessary, assuming expertise and competence with a couple, even when competent working with individuals,

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Case Illustration 11.1

Moving From Individual to Couple Counseling

Dr. Hansen received a call from Mrs. Alice Robinson, who described herself as “a little down” and unclear about the direction she wanted to go with her career. Dr. Hansen, a certified vocational counselor, sched- uled to meet with Mrs. Robinson to begin the process of a vocational career assessment.

Following the initial intake, Dr. Hansen concluded that Mrs. Robinson, while interested in vocational and career counseling, was doing this in reaction to what she “perceived to be a failing marriage.” Dr. Hansen saw Mrs. Robinson three more times with the intent of more clearly identifying Mrs. Robinson’s goals for counseling. Through these three sessions, Dr. Hansen came to realize that Mrs. Robinson was seriously depressed. She revealed a long-standing history of depression and self-medicating alcohol consumption. She also described considering committing suicide on more than three occasions in the past month. Further, Mrs. Robinson noted that she is unable to eat, has lost approximately 20 pounds in a one-month period, and is having difficulty sleeping. The root of this depression, according to Mrs. Robinson, is the fact that “she cannot communicate” with her husband, and she knows unless something is done, they will get a divorce. And according to Mrs. Robinson, she simply “would not, could not live without him!”

Mrs. Robinson described how long she has been wanting to seek counseling for herself (her depression) and for she and her husband. But according to Mrs. Robinson, she just didn’t feel comfortable seeking help since there are so many “wacko doctors” out there. Mrs. Robinson expressed her comfort and trust with Dr. Hansen and asked if he would help her and her marriage.

Dr. Hansen, while being trained and supervised in career/vocational counseling, agreed to work both individually with Mrs. Robinson in order to assist her with her depression and also to set up an arrangement to see her and her husband as a couple to start “communications training.”

invites unethical behavior and a failure to provide appropriate standard of care. Thus, Dr. Hansen needs to reflect not only on his own training (formal and informal) and supervised experience working with clinically depressed individuals but also on the extent of his preparation in systemic-relational

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treatment before proceeding to treat if the couple. This would be essential for ethical, competent practice.

Helpers, regardless of their knowledge and skill, cannot provide every service needed by every client. Ethically, therefore, a helper needs to know not just the when and how of applying helping skills but also when the situ- ation is beyond his or her capabilities or when the boundaries of his or her competence have been exceeded.

Knowing When to Refer

Knowing when to refer is not always easy. At a minimum, the ethical helper will refer anytime it is determined that she or he is unable to pro- vide the professional, competent services required. The ethical, competent helper needs to be aware of his or her areas of expertise, the kinds of sup- port and supervision available, and an accurate sense of his or her own time, energy, and availability to take on a particular case. When any of these areas are in question, referral should be considered.

If Dr. Hansen (see Case Illustration 11.1) reflected on his own decision- making, he might have concluded that a trained, experienced marriage relational counselor might more competently provide the services that Mrs. Robinson and her husband currently need. As such, he would have made a referral rather than attempted to provide those services himself.

Each practitioner can provide competent service, but no one practitioner can be a master of all the knowledge and skills required to competently address the myriad of situations and clients presented. As each profession develops its knowledge base and refines the skills required, it will become increasingly incumbent on the practitioner to recognize the limits of his or her own com- petency and the richness of resources available through the use of referral.

Knowing Where to Refer

In making a competent referral, the practitioner needs to understand the nature of the specific support and services requested. As such, the ethical, competent helper will have a cadre of available referral sources whose char- acter and capacities are known (Zhang & Parsons, 2016). Building a referral system, branching through the surrounding geographic area, is essential. This referral network should include a variety of professional and indigenous helpers, including psychologists, psychiatrists, social workers, ministers, physicians, clinics, social service agencies, hospitals, and so on.

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Exercise 11.3

Developing a Referral Network

Directions: You can begin developing a referral network by contacting local agencies and human service providers by phone, letter, or e-mail and gathering the following information:

Name: ___________________________

Address: ___________________________

Phone: ___________________________

1. What is the purpose or mission of your professional service or practice?

2. What population (age, gender, socioeconomic position, ethnic- ity, etc.) is best served by your service?

3. What type of difficulty, problem, or concern is most often addressed by you/your service?

4. What resources are available (e.g., 24-hour hotlines, medical facilities, educational materials, housing, job placement, etc.)?

5. What is the procedure or process for gaining access, making an appointment, or seeking assistance?

6. What is the general therapeutic theory or model employed?

Being fully versed on the resources available not only enables the ethical helper to select the service(s) that most effectively meet the client’s needs but also allows the helper to explain the reason for and the process of referral to the client. Being familiar with the services available allows the helper the opportunity to highlight the unique qualifications of the person or program to which the client is being referred, along with other information needed to make for a smooth and comfortable referral and transition for the client.

While a listing of various human services agencies and providers may be obtained by contacting the local county government or mental health/ (mental retardation) intellectual disability agencies listed in your phone book or on a webpage, more personalized knowledge is required for adequate referral. Exercise 11.3 is offered as a guide for developing this personalized, referral network.

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Making the Referral

Recognizing the need or value of referral is only the first step. In addition to recognizing the need and having available resources to whom to refer, the competent helper will also have the skill to assist the client to accept and embrace this referral. It is not unusual for a client to interpret the suggestion of a referral as a sign of rejection or as evidence of the hopeless nature of his or her condition.

The competent, ethical helper will present the idea of referral in a way that it is seen as a continuing, productive step in the helping process that, far from being evidence of rejection, it is evidence of the helper’s concern. And rather than evidence of the hopelessness of the situation, it is evidence of the clarity of the nature of the problem and the reality of the existence of a resource with a record of success in these situations. Consider the dialogue presented in Case Illustration 11.2.

7. What are the training levels of the helpers who provide these services?

8. Are there fees? How much? Payment plans? Sliding scales? Insur- ance? Other?

9. Who is the contact person?

10. Is there a waiting list?

11. Other information (e.g., special services, general impressions, etc.).

Case Illustration 11.2

Preparing Margaret for Referral

Linda is a master’s-level mental health counselor working for an Employee Assistance Program (EAP). Her training is in counseling psychology, and she has experience working with individual, solution- focused approaches to counseling. As a counselor in an EAP, she is contracted to provide a maximum of six sessions of direct service, while overseeing and case managing all clients whom she refers for

(Continued)

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ongoing assistance. Margaret, her client, has come to her because her husband “kicked her out” of their house and is filing for divorce. Margaret, in addition to being depressed about the situation with her marriage, is in crisis over her current living conditions. The exchange occurs near the end of the first session.

Linda: Margaret, you have certainly been open and honest with me. And I know that speaking about the marriage and your relationship with Tom has at times been very upsetting.

Margaret: It has been easier than I thought. You are a very kind person and a good listener.

Linda: Thank you. But as we’ve talked, it has become clear to me that of the things you are concerned about, the one thing that seems to need immediate attention, is helping you with your housing problem.

Margaret: Yeah, I don’t have any money to go and get a new apartment right now and last night I slept in the car. I know I have enough money to go to a motel for a night or two, but I don’t know what I can do (starts to cry). Where can I go?

Linda: You are correct in saying that you can’t continue to sleep in the car, and finding an answer to your question of, where can you go? should be our primary concern. Do you agree?

Margaret: Yes (crying).

Linda: Housing or social service support for displaced women is not something that we provide here at the EAP or that I am very experienced with.

Margaret: (interrupting): Oh, NO! You have to help me . . .

Linda: It is going to be all right. I am going to help. Even though I do not work with these types of situations, I know someone who can really help us, who has a lot more experience in these situations. So what I would like to do is call Ms. Anderson over at the Women’s Center and see if she has the time to talk with us and see you today. The Women’s Center is right around the corner from here and it provides ongoing counseling for women who are in situations just like yours.

(Continued)

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As evident in the exchange (see Case Illustration 11.2), presenting the client with a referral needs to be done as a hopeful, positive step in the helping process. The helper needs to convey to the client that this is not an abandonment but an extension and refinement of the helping process. In making a referral the helper should

• Be clear and direct about the goal and expectation for seeking referral • Confront what referral is NOT, that is, it is not a rejection or a state-

ment of hopelessness

• Share information about the referral source, nature of service, costs, location, and so forth

• Discuss the client’s feelings and concerns • Answer all client questions regarding the referral • Reassure the client about the value of the referral • Assist the client in making the initial contact • Establish a mechanism for follow-up with each other. Encourage

the client to let the helper know how the initial visit went

They also have resources for temporary housing and even help women find low-cost housing. Plus, once they help you get settled, they can help you with some of the job training we started discussing.

Margaret: But how about you . . . ? I like you . . .

Linda: And I like you. In fact, I really want you to get the best help you can get and I think the Women’s Center is the answer. But I can still help, by talking with Ms. Anderson and telling her some of things you have shared with me, especially things about your current concerns and some of your goals. I could also work with you and Ms. Anderson, if that makes sense after talking with her. And if you want to come back to talk with me, or if we want to look into another referral source, we could do that as well. So how do you feel about me calling and seeing if we can set up an appointment for you?

Margaret: Okay . . . but I can still call you if I need to?

Linda: Absolutely, and I will call you to see how things are going after you have had a chance to work with the Women’s Center.

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If you are requesting special services for a client from a colleague, it is important to provide the colleague with the information about the case that is necessary to support the goals of the referral. Needless to say, it is essential to gain the client’s consent for such collaboration prior to speaking with the professional to whom you are referring. Once the referral contract has been established, it is important for the referring helper to back off from case involvement unless specifically requested by the attending professional.

● RECENT LEGAL DECISIONS

Malpractice or professional liability lawsuits are quite often based on the issue of therapist negligence. A client, who in legal proceedings is the plaintiff, would assert that the helper has breached the standard of care. A simple way of looking at negligence is to think of it as the failure to do something that a reasonable person in ordinary circumstances would do or something a reason- able person in ordinary circumstances would not do. When viewed through the lens of the professional helper, negligence would be a failure to do that which the typical clinician would do or not do in that same situation. While malpractice requires a demonstrating of injury even when such proof of injury is absent, complaints to professional ethics committee or regulatory agencies (e.g., licensing boards) can result in sanctions.

The legal concept of negligence is based on the premise that all members of society owe to one another the duty to exercise a certain inherent standard of care. In most cases, the courts will look to the profession itself to define which standard should be used. The standard of care has been described as the qualities and conditions that prevail, or should prevail, in a particular mental health service, and that a reasonable and prudent practitioner follows (Zur, 2007). The standard is based on community and professional standards and, as such, professionals are held to the same standard as others of the same profes- sion or discipline with comparable qualification in similar localities.

Case law on the standard of care question varies around the country. Some courts will put the emphasis on “accepted” practice, others on what is “customary.” In this latter case, an attorney will develop evidence to define the customary standard applied by others in the field, with “field” defined in the most specific sense possible. For example, when a clinical psychologist who has been trained in cognitive techniques offers this orientation explic- itly to his or her clients, when he comes to the courtroom, the standard for his or her performance is predefined. The cognitive school is recognized by the community of psychologists as a distinct and viable orientation, with well-defined standards for training and clinical guidelines. Should this

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While the threat of malpractice can certainly motivate one to perform within the boundaries of his or her training, it is not insurance in and of itself that such ethical, competent performance of duty will occur. As with all of the ethical standards and practice guidelines, directives to provide competently within the standard of care are or can be a mere statement of expectation rather than an operative schema guiding practice decisions.

As ethical practitioners, we need to move the concepts and principles discussed within this chapter from levels of comprehension to incorporation as personal values and moral imperatives. Once assimilated as a personal value and moral response, acting competently will be a simple consequence of being competent in the broadest sense of the term. The final exercise (Exercise 11.4) is provided to assist you in adding the affective, personal component to this theoretical, conceptual discussion.

psychologist be operating without the appropriate training or outside the customary procedures for a cognitive therapist, he or she may be vulnerable to negligence and malpractice. Therefore, not only do helpers need to legally perform within their scope of training, but they also must perform in ways that are typically or customarily associated with that form of service. Help- ers who develop or subscribe to innovative therapies might find themselves having to prove that a “respectable minority” in their profession concurs in their techniques or treatment strategies.

An alternative approach to negligence, malpractice, and the issue of standard of care is that derived not from one’s own training but from the clinical imperatives of the client’s condition. In Hammer v. Rosen (1960) the court ruled that a therapist’s (psychiatrist) decision to beat his patient as part of therapy was a prima facie case of malpractice. The court noted that some acts are so obviously unacceptable that expert testimony is not needed to justify the conclusion of malpractice. If a nontraditional therapy is employed, documentation of the reasons for its choice rather than a more traditional approach, along with expert testimony showing the efficacy of the therapy in a similar situation and/or its theoretical and scientific bases, may be needed should a malpractice action be filed (Dickson, 1998). It could be assumed that the same logic may be applied to the situation in which a practitioner used a traditional but less than effective strategy of intervention. The theoretical and empirical base for that decision may be essential should a malpractice action be filed.

BEYOND PROFESSIONAL STANDARDS: A PERSONAL MORAL RESPONSE

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Exercise 11.4

Personalizing the Importance of Competence

Part 1: Below you will find a list of presenting concerns. As you read the list, place a check mark under the column indicating whether you would work with the person and provide service or refer the person to another helper. If you are currently in a formal degree/ training program, answer the question as if you had just completed that training.

Presenting Concerns Provide Service

Refer to Another Helper

A person with anxiety about making a career decision

A person grieving the recent death of her parent

A person thinking about leaving his partner

A person concerned about the possibility of having a drinking problem

A person who has questions about her sexual orientation

A person having academic difficulties in college

A person who feels extremely depressed

A person who is experiencing headaches and muscle tensions as a result of job- related stress

A person who is concerned about his explosive temper

A person who is having conflict with her adolescent child, which at times has exploded into physical confrontations

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Part 2: Now for each of the above, reconsider your decision. This time assume that the client was viewed by you with the same level of care and concern as you would have for someone very close to you (e.g., family member, spouse, best friend, etc.). Once you personal- ized the level of concern for the client, did you adjust your original decisions? What might this say about your customary standard of care? Consider steps you can take to approach all clients with the same depth of concern and provision of quality, competent service.

Part 3: For those situations in which the decision was to refer, begin to establish referral resources that you would feel comfortable referring all clients to, including a person who was personally very close to you.

The scenario that opened this chapter not only revealed Ms. Wicks’s (Michelle’s) deep concern for her client, Maria, but her personal awareness of the possible limitations to her own competence and ability to assist Maria. With these two conditions in place, Michelle sought out a peer for consulta- tion and possible referral.

Michelle: Hi, Lynn. Do you have a minute?

Lynn: Sure, Michelle, what’s up?

Michelle: I’ve been working with this girl, Maria, and we have a real good working relationship, but I don’t feel like I have a huge grasp of what is going on or that I am approaching this situation the best way that I might. I explained this to Maria, and she has given me written permission to speak with you about the case. I know you are really busy, but I was hoping that you could provide some supervision around this case to see if you feel like I’m on track and using the best approach.

Following a discussion of case details, their conversation continued.

Lynn: It really does appear that you have gained Maria’s trust and given her recent experience and background, that was not an easy task.

Michelle: Oh, thanks . . . you are right, it wasn’t the easiest, but that’s why I want to do the best for her.

CONCLUDING CASE ILLUSTRATION ●

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Lynn: Well, your specific solution-focused approach really does appear to be effective, especially in helping her with the “life crisis” of finding a place to live, support herself, and essentially stay safe. So, I would suggest you continue to strategize with her the way you have been and identify additional resources that she can use . . .

Michelle: I will, but as I said, I feel there is much more here than the immediate crisis.

Lynn: I agree . . . It is very clear that Maria has some real issues with her family, especially her father, and I think one of the goals you could try to work on would be to get her to feel safe and crisis- free so that she might be willing to work with her family in some family therapy.

Michelle: We touched on that a couple of times, but she was resistant. But as you were speaking, I remembered that her resistance did seem to be diminishing. It appears the more she feels comfortable with me and what we are planning, the more she may be willing to risk some family sessions! But I am really not trained in family work. I mean, I’ve had a course, but that’s not something I’ve done. So if she agrees, I would like to refer her. I really respect you and the work you do with families, and I have heard great things about Dr. Hemingway and his work with families. Would it be okay if when we get to that point, I give her your name along with Dr. Hemingway’s?

Reflections

1. In reviewing the case, can you see evidence of the helper (Ms. Wicks) placing the client’s welfare above her own image and ego?

2. Identify two specific things done by Ms. Wicks that reflect her aware- ness of the need to provide competent and efficacious service.

3. In addition to having a course in family-systems therapy, what would you suggest is minimally required before one engage in such an intervention?

4. What might you suggest Ms. Wicks do prior to including Dr. Hemingway on a referral list?

5. What might you suggest Ms. Wicks do to prepare Maria for referral? What role could Ms. Wicks continue to play?

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As with all of the previous cooperative learning exercises, the current exer- cise is designed to help you personalize the material and begin to move your understanding to professional practice. Therefore, before proceeding to the next chapter, read and respond to each of the following. Working with colleagues, classmates, or supervisors, share your insights and develop the comprehensive plan for developing increased levels of competency.

Goal Identification: Briefly share your vision or goal in terms of the type of work you would like to do as a practitioner—that is, the type of client you envision working with, the nature/scope of problems, and the setting in which you wish to work.

Legal Requirements: Identify the professional standards and minimal requirements necessary to perform the tasks described in the question above. What are the specific licensing and certification requirements in your state that apply to the practice you envision performing?

Contact: Contact one professional currently practicing in an area similar to the one that you have identified as your professional goal. Identify the level of training, experience, and model this practitioner employs. Identify clients or presenting complaints that this professional feels are outside the boundaries of his or her competence and gather two resources to which he or she refers.

Contract: Finally, in discussion with your colleague, classmate, or supervisor, compare your current level of training and experience to the standards established within your state and the level of expertise identified by the professional you contacted. What specific gaps exist and what is your plan to fill those gaps in competency?

COOPERATIVE LEARNING EXERCISE ●

SUMMARY ●

• Being competent means that the helper has the knowledge, skills, and abilities needed to perform those tasks relevant to that profession. Competence is defined in relative terms, most typically using the conduct of others within the profession as the comparative standard.

• Competence can be developed from formal training, as might be found in graduate training or training for certification and licensure.

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Further, all the codes of conduct call for practitioners to be current with emerging knowledge relevant to their profession. It is incum- bent upon the ethical practitioner to upgrade his or her knowledge and skill through participating in continuing education experiences and peer consultation.

• Most malpractice cases turn on the question of negligence, which sug- gests that the practitioner failed to meet the relevant standard of care. The question of negligence will be determined by the debate over the clinical correctness and efficacy of the treatment that was given, along with the practitioner’s judgment in choosing it.

• Malpractice or professional liability lawsuits are based on negligence theory. That is, a client would assert that the helper has breached the standard of care. A review of recent court decisions could lead to the assumption that where a practitioner used a traditional but less than effective strategy of intervention, the theoretical and empirical base for that decision may be essential should a malpractice action be filed.

• The standard of care and the definition of appropriate treatment are typically determined by comparing the practitioner’s performance with that of other professionals in the same community with compa- rable training and experience. However, as the professions and the research identify specific strategies with demonstrated effectiveness, these interventions become the standard of care.

• Practitioners bear a fundamental ethical responsibility to use, when possible, interventions that work and to subject any intervention they use to scientific scrutiny.

• In order to be effective in their practice, human service providers must blend the method and findings of research with the realities of their professional practice. As practitioner-researchers, they will need not only to interact in the moment but also to reflect on and cri- tique their own interactions. Action research methodology provides practitioners with the means of acquiring these valid, useful data and results in the development of effective strategies of professional practice.

• Knowing when to refer is not always easy, and there are no simple or clear answers.

• At a minimum, the ethical helper will refer anytime it is determined that he or she is unable to provide the professional, competent ser- vices required. In addition to recognizing the need and having avail- able resources to whom to refer, the competent helper will also have the skills to assist the client to accept and embrace this referral.

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action research malpractice

best practice managed care

brief therapy negligence

certification peer consultation

competence professional development

continuing education referral

customary referral network

efficacy of the treatment regulatory bodies

formal training standard of care licensing

IMPORTANT TERMS ●

ADDITIONAL RESOURCES ●

Bean, R. A., Davis, S. D., & Davey, M. P. (2014). Clinical supervision activities for increasing competence and self-awareness. Hoboken, NJ: John Wiley & Sons

O’Hagan, K. (2007). Competence in social work practice: A practice guide for stu- dents and professionals (2nd ed.). Philadelphia, PA: Jessica Kingsley Publishers.

Shelton, C. F., & James, E. L. (2005). Best practices for effective secondary school counselors. Thousand Oaks, CA: Corwin Press.

Web-Based

American School Counselor Association. (n.d.). ASCA school counselor com- petencies. Retrieved from http://schoolcounselor.org/asca/media/asca/home/ SCCompetencies.pdf

Caudill Jr., B. (n.d.). Malpractice & licensing pitfalls for therapists: A defense attor- ney’s list. Retrieved from http://kspope.com/ethics/malpractice.php

Fairburn, C. G., & Cooper, Z. (2011). Therapist competence, therapy quality, and therapist training. Behaviour Research and Therapy, 49(6–7), 373–378.

Martz, E., & Kaplan, D. (2014, October). New responsibilities when making referrals. New Concepts in the ACA Code of Ethics. Retrieved from http://www.counseling .org/docs/default-source/ethics/ethics_ocober-2014.pdf?sfvrsn=2

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● REFERENCES

American Association for Marriage and Family Therapy. (2015). Code of ethics. Retrieved from http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/ Code_of_Ethics.aspx

American Counseling Association. (2014). Code of ethics and standards of practice. Alexandria, VA: Author.

American Psychological Association. (2010). American Psychological Association’s ethical principles of psychologists and code of conduct. Retrieved from http:// www.apa.org/ethics/code/principles.pdf

Bennett, B. E., Bryant, B. K., VandenBos, G. R., & Greenwood, A. (1990). Profes- sional liability and risk management. Washington, DC: American Psychologi- cal Association.

Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits- Christoph, P., . . . Woody, S. R. (1998). Update on empirically validated thera- pies, II. The Clinical Psychologist, 51(1), 3–16.

Cohen, J., Marecek, J., & Gillham, J. (2006). Is three a crowd? Clients, clinicians, and managed care. American Journal of Orthopsychiatry, 76(2), 251–259.

Daniels, J. (2001). Managed care, ethics, and counseling. Journal of Counseling & Development, 79(1), 119–122.

Dickson, D. (1998). Confidentiality and privacy in social work: A guide to the law for practitioners and students. New York: The Free Press.

Gottlieb, M. C., & Younggren, J. N. (2009). Is there a slippery slope? Considerations regarding multiple relationships and risk management. Professional Psychology: Research and Practice, 40(6), 564–571.

Hammer v. Rosen, 165 N.E. 2d 756 (1960). National Association of Social Workers. (2008). Code of ethics. Retrieved from

https://www.socialworkers.org/pubs/code/code.asp O’Donohue, W., Buchanan, J. A., & Fisher, J. E. (2000). Characteristics of empiri-

cally supported treatments. The Journal of Psychotherapy Practice and Research, 9(2), 69–74. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3330591/

Task Force on Promotion and Dissemination of Psychological Procedures. (1995). Training in and dissemination of empirically validated treatments: Report and recommendations. The Clinical Psychologist, 48(1), 3–23.

Zhang, N., & Parsons, R. D. (2016). Field experience: Transitioning from student to professional. Thousand Oaks, CA: Sage.

Zur, O. (2007). Boundaries in psychotherapy: Ethical and clinical explorations. Washington, DC: American Psychological Association.

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