Ch 9: Intimate partner violence

Overview:

-          Can range from harsh criticism to aggressive brutality between adults in an intimate relationships

-          Child abuse and elder abuse are considered domestic violence. Treated different legally under those who cannot help themselves (though long-term IPV’s may also be stuck in the situations.

-          Battered wife syndrome: chronic yet inescapable victimization

-         

3 ways to distinguish subtype of offenders

o   Severity of violence

o   Generalist of violence

o   Presence/absence of psychopathology/personality disorders

-          2 types of intimate violence:

o   Male power and dominance

o   Mutual conflict between partners

Cultural, value-power, and systemic considerations

-          

Cultural dimensions have beend ID’d as considerations affecting IPV that include gender, race, and ethnic/national origin. Other considerations include religion, sexual orientation, and disability

-          Important in avoinding nondiscrimination elements of ethical codes noted previously

-          There isn’t necessarily noe set pattern to address and discuss IPV in therapy. Notes layers of values and powers the help determine how things should be handled

-          Values:

o   Personal values: personal beliefs or values may shade the therapist’s capacity to work with couples with IPV or build alliance with one or the other client

o   Professional layer of values: hierarchy or duties, attending to concerns about client safety and therapist role

o   Institutional values: associated with social custom, legal precedent, and risk management in liability may converge/conflict with personal/professional values

-          Powers:

o   Legitimate power: to compel the actions of others through the use of powers that oten align with inst. Values

o   Referent power: aligned with personal values….entails using one’s persuasive ability to charm, manipulate or impress based on one’s status. This can be problematic as change come from one charismatic pressures more than real desire.

o   Expert power: informed by professional values…most viable framework for influencing clients in and IPV circumstance. It’s giving care that is tempered by reality and professionalism.

Principles, traditions, and uniquenessses

This discussed how dealing with IPV’s would be in connection with the basic principles to therapy.

-          Beneficence: focus that benefits > harm/risks. Statistically, women are usually better off leaving the situation than remaining

-          Nonmaleficence: do no harm – leaving a person unchallenged/unaided in a dangerous situation can be seen as broaching this

-          Principle of justice: equal treatment. Because this is considered a unique circumstance, unique treatment would be needed

-          Fidelity: faithfulness and loyalty to clients. Discusses really assuring loyalty with the victimized above maintenance of the relationship and the victimizer

-          Autonomy: there should be a cautious balance between no misusing their position, becoming overly directive and leading to transference issues. But also, the situation may warrant more directed therapy

Decision making models and options for resolution

Kitchener’s four processes:

-          Entails sensitivity, knowledge, and perceptiveness to interpret that a surrounding requires an ethical decision

-          Emph on ethical course of action. Actions reflecting intuition at the personal layer of vals

-          Integration of personal and professional val in a decision

-          Action

Treatment alternatives:

Feminist lit

-          Reinforcing the predominant societal conditioning that made them passic and dependent. …recognizing the potential need to patiently await developmental movement toward increased independence, positive self-worth, and autonomous action

Four interrelated clinical positions as a means of ensuring ethical practice

-          Overt goal of therapy: stopping intrafamily violence whenever it’s present

-          Intrafmily violence is the focus, neutrality should not be a primary therapeutic procedure

-          Therapists should use their ethical judgment in asserting indic responsibility for violent behavior

-          Family therapy is contraindicated unless the violent fam member is able to contract or nonviolence

Wilcoxon Ch. 7 Summary

• Establish the importance of external factors, such as institutional traditions and values, as the context for ethical care with couples and families

 • Clarify the effects of meta-issues (i.e., opportunities, vulnerabilities, and exceptions), many of which can be only minimally altered by therapists, couples, or families

-       When there’s a choice to be made between two technically correct paths. 

-       Diversity aspects (economically, racially, situational, etc.)

o   An appreciation for the distinctions in client’s circumstances separates multicultural sensitivity from multicultural competence.  How do we become competent?

-       Vulnerability aspects

o   Are our trauma clients ready to work?  Or are we pushing our timing on them?  We need to be aware of their resistance, timing, complexity, depth, etc. 

-       Exceptions:

o   Not every client is the same.  What worked for one may not work for the other. 

 • Examine the impact of and ethical concerns associated with diagnosis and managed mental health care as contextual frameworks for therapy with couples and families

-       DSM V deals with mental disturbance that occurs within an individual patient.  Relationship and family issues are outside the domain. 

-        DSM deals with an IP, rather than a systems perspective.  If we subscribe to this so we can get reimbursed, are we really subscribing to the idea that there is always a scapegoat in the family?

-       What does releasing diagnostic codes mean? (In terms of informing our clients and getting their consent for releasing diagnostic codes)

-       “We need your help in differentiating those with legitimate mental disorders and those who simply have problems.”  In our program, we always look for a diagnosis, is this a problem?  What do you guys think?

-       Competence to diagnose requires CE and a vigilant effort to stay on top of changes. 

 • Contrast the institutional and professional value conflicts practitioners may face in their efforts to balance ethical care with compliance obligations.

-       Managed mental health care.  What is this exactly?

-       Under most managed health care systems the therapists must be competent in brief therapy with a limited number of sessions.  Could we do this?

-       Dr. Crane—how many sessions is “brief therapy”?

-       Since on page 134 they found a study reporting that brief therapy usually exacerbated people’s symptoms and had them coming back not too much later, are there any insurances that cover long-term therapy?

-       Sometimes management systems demand things that conflict with the client’s best interest, so the therapist should try to bring that to the attention of both parties and work in favor of the client. 

If a law is in contrast with the MFT Code of Ethics, we are allowed to follow the law without fear of disciplinary action by the AAMFTRB. 

Wilcoxon Chapter 8- Contemporary Ethical Issues: Practice Matters

Objective of the chapter: To examine ethical issues associated with common contemporary practice concerns.

This chapter offers discussion and recommendations for therapy matters associated with the following:

• Multiple relationships with clients and others
• The various uses of technology in therapy with couples and families
• Confidentiality, welfare, and protection considerations for clients reporting HIV/AIDS conditions
• Research and publication as a means of informing ethical practice

Multiple Relationships with Clients or Others

A multiple relationship is where an MFT assumes two roles with a client. 

This can be a problem because they are sometimes unavoidable, difficult to recognize, and could either be potentially harmful or beneficial. 

They can be simultaneous or sequential

Ethical Codes and Multiple Relationships

All codes and standards indicate that multiple relationships may be harmful, exploitive, and need to be handled especially since sometimes they are unavoidable, especially if you live in a small/rural community.

Never engage in a sexual relationship with a current client!

Each of the codes of ethics has rules about dual relationships. They all say no sexual relationships, but social work is even more strict. They say no physical touch if it would harm the client. 

The ACA says no sex until 5 years after terminating a client, but APA and AAMFT say 2 years. 

There are 3 guidelines to help us differentiate between dual role relationships and the rest of the chapter refers back to these:

1. Compatibility of expectations
2. Divergence of obligations
3. The power and prestige differential

Compatibility of Expectations

"As the difference between the expectations of the therapist and client increases, the potential for misunderstanding and harm increases"

• You need clear expectations about what the therapeutic relationship is! If your expectations are unclear, the client's will be even more unclear. 

Divergence of Obligations

"As the divergence between the obligations imposed by different roles increases, the potential for divided loyalties and loss of objectivity increases."

• For example, the roles of therapist and friend are generally divergent
• "Counselors who are tempted to enter a counseling relationship with a friend might do well to ask themselves whether they are willing to risk losing the friendship."

Power and Prestige Differential

"As the difference in power and prestige increases... the potential likewise increases for exploitation on the part of the therapist and an inability on the part of clients to remain objective about their own best interests."

• therapists often have considerable power over their clients even after termination
• This is where those intimate relationships come in. They typically do more harm than good for the client, even after the case has been terminated. 
• "Although few would suggest that therapeutic contracts ought to carry a lifelong obligation, it is equally implausible to suggest that the formal ending of a contract should entitle a therapist to engage in activities with a former client that will undo the benefits that therapy promoted."

Taking Appropriate Action

"When therapist client expectations are clearly defined and compatible, role obligations are convergent, and the power differential is small, there is much less danger that harm will ensue."

TECHNOLOGY

It can be used as a means of enhancing or exploiting therapeutic relationships

Technology in Information Management

"Identity information, standardized forms, diagnostic and treatment data, billing, progress notes, and archival records that create databases for therapy practices. 

We also transmit data electronically via fax, etc.

Technology as a practice resource

Sometimes we give our clients websites to look at, but make sure you're confident that ALL of the info on that site will be beneficial to the client's treatment. 

There's also a new thing called DIY Testing where people can answer questions about what they're going through and symptoms and they can give them a provisional diagnosis and advise them as to what paths of treatment they should take. While right now it's not super reliable, this could improve and become a great tool for us in the future!

• There's also technology-based supervision and consultation

Technology as a Therapeutic Modality

You can use email, skype, video chat, phone calls, etc. 

"Differences in process and outcomes among he three treatments were small and clinically promising"

Ethical Issues in the use of technology: Concerns for the ecology of therapy:

This could have a cultural problem... increase of efficiency and rapidity in communicating and work is great for westernized society, but what if that's repressive for some clients? 

Therapy is a process that often involves  patience and deliberation... but can technology undermine that?

If a therapist uses email as a primary means of therapy and communication this could be problematic if a client has an emergency/is suicidal and they can't get a hold of their therapist immediately. 

HIPPA laws come into place in order to regulate the electronic storage, receipt, and transmission of client data. 

The ethical principles of nonmaleficence, justice, and fidelity come in big time with this issue.

Electronic/Text Messages and Social Networks

This could make things sticky if you use too many means to communicate with your client- for example a therapist who tweets and emails and texts their client then the client gets the wrong idea about their relationship. When the therapist then puts an end to it, the client reports him/her for being unethical and confusing them about the parameters of the relationship.

HIV/AIDS, Confidentiality, Client Welfare, and Public Protection

The Tarasoff decision comes into play here big time! 

"A therapist is not to be encouraged routinely to reveal such threats since such disclosures could seriously disrupt the patient's relationship with the therapist and with the person threatened. On the contrary, the therapists obligations to the patient require that he [or she] do so discreetly and in a fashion that preserves the privacy of the patient to the fullest extent compatible with the prevention of a threatened danger."

So, basically... we need to take into account how in danger others are if our clients tell us they are HIV positive/have AIDS.

The danger must be FORESEEABLE before we can act on any information. So, if they are engaging in high risk behaviors and immediately endangering others, we need to do something.

"Jeopardizing the supportive nature of therapy for the client (and possibly others) must be a significant consideration in disclosure decisions.

Nonmaleficence is the preferred guideline for this scenario. 

"A therapist should not be encouraged routinely to reveal such threats... unless such disclosures are necessary to avert danger to others."

Research and Publication: Informing Ethical Practices

Practices that are not grounded in research can be the basis for nonmaleficence or, more important, harm for clients. 

"A practitioner who remains uninformed about a practice either through lack of interest or through bias agains alternatices may threaten beneficence, indulge referent power, and promote personal values at the expense of client care."

"Published research is a means by which therapists can (a) share information, (b) promote themselves, and (c) succeed in academia.