Ethics in Mental HealthErin A. Alexander, LPCRebecca D. Nate, LPC

Objectives

● Participants will be able to identify their professional responsibility as it relates to patient suicide risk

● Participants will be able to identify the specific information needed when reporting child abuse/neglect

● Participants will be able to identify the updates to the 2014 American Counseling Association Code of Ethics, and the updates to the Health Insurance Portability and Accountability Act

● Participants will be able to apply their knowledge of ethics to case scenarios

Professional Responsibility and Suicide Risk

The majorityof tort actions filed against mental health professionals subsequent to a client's suicide are based onallegations of negligence (such as failure to follow established prevention guidelines) or malpractice (such asmisdiagnosis, absent or inappropriate risk assessment, or inappropriate treatment interventions whensuicide risk was identified).

Did You Know?

Asking the client if he or she is suicidal, if he or she has a plan, and if he or she has the means to carry out theplan is insufficient and reflective of negligence.

Assessment of Suicide:

Current presentation of suicidality

• Suicidal or self-harming thoughts, plans, behaviors, and intent• Specific methods considered for suicide, including their lethality and thepatient’s expectation about lethality, as well as whether firearms are accessible• Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety• Reasons for living and plans for the future• Alcohol or other substance use associated with the current presentation• Thoughts, plans, or intentions of violence toward others

Assessment of Suicide

Psychiatric illnesses (psychosocial history)

• Current signs and symptoms of psychiatric disorders with particular attention to mood disorders (primarily major depressive disorder or mixed episodes), schizophrenia,substance use disorders, anxiety disorders, and personality disorders(primarily borderline and antisocial personality disorders)• Previous psychiatric diagnoses and treatments, including illness onset andcourse and psychiatric hospitalizations, as well as treatment for substance usedisorders

Assessment of Suicide

History (Psychosocial history)

• Previous suicide attempts, aborted suicide attempts, or other self-harmingbehaviors• Previous or current medical diagnoses and treatments, including surgeries orhospitalizations• Family history of suicide or suicide attempts or a family history of mental illness, including substance abuse

Assessment of Suicide

Psychosocial situation (Current and Psychosocial history)

• Acute psychosocial crises and chronic psychosocial stressors, which may includeactual or perceived interpersonal losses, financial difficulties or changes insocioeconomic status, family discord, domestic violence, and past or current sexualor physical abuse or neglect• Employment status, living situation (including whether or not there are infants orchildren in the home), and presence or absence of external supports• Family constellation and quality of family relationships• Cultural or religious beliefs about death or suicide• Individual strengths and vulnerabilities

Assessment of Suicide

Coping skills (Psychosocial history)

• Personality traits• Past responses to stress• Capacity for reality testing• Ability to tolerate psychological pain and satisfy psychological needs

Patient Reliability and Veracity

Patients are not always reliable sources of information,especially about their suicidal wishes and impulses.When a suicide has occurred, one of the things ourexperts look for is evidence that the caregivers reliedsolely on the patient for information about suicide risk.

Patient Reliability and Veracity

Clinical decision makers know, or should know, the many reasons patients often provide inaccurate information in assessments. Cognitive deficits or psychosis may make them incapable of giving a complete history. They may want to avoid hospitalization or restriction. If already hospitalized, they may want to be discharged or given a pass. They may try to be honest with the examiner but be unable to assess their own future impulses. They may simply want to mislead the clinician into believing they aren’t suicidal so they will be free to kill themselves without interference. By the same token, so-called no-self-harm “contracts” are unreliable.

Where to Obtain Information

● Family Members, significant others● Other mental health professionals● Medical professionals

Be sure to have signed consents in the file and signed coordination of care forms in the file at the beginning of treatment

Admission Generally Indicated

After a suicide attempt or aborted suicideattempt if:• Patient is psychotic• Attempt was violent, near-lethal, or premeditated• Precautions were taken to avoid rescue ordiscovery• Persistent plan and/or intent is present• Distress is increased or patient regrets surviving• Patient is male, older than age 45, especially withnew onset of psychiatric illness or suicidalthinking

Admission Generally Indicated

• Patient has limited family and/or social support,including lack of stable living situation• Current impulsive behavior, severe agitation, poorjudgment, or refusal of help is evident• Patient has change in mental status with ametabolic, toxic, infectious, or other etiologyrequiring further workup in a structured settingIn the presence of suicidal ideation with:• Specific plan with high lethality• High suicidal intent

Admission May be Needed

• After a suicide attempt or aborted suicideattempt, except in circumstances for whichadmission is generally indicated

Admission May be Needed

In the presence of suicidal ideation with:• Psychosis• Major psychiatric disorder• Past attempts, particularly if medically serious• Possibly contributing medical condition (eg,acute neurological disorder, cancer, infection)• Lack of response to or inability to cooperate withpartial hospital or outpatient treatment

Admission May be Needed

• Need for supervised setting for medication trialor electroconvulsive therapy• Need for skilled observation, clinical tests, ordiagnostic assessments that require a structuredsetting• Limited family and/or social support, includinglack of stable living situation

Admission May be Needed

• Lack of an ongoing clinician-patient relationshipor lack of access to timely outpatient follow-up• In the absence of suicide attempts or reportedsuicidal ideation/plan/intent but evidence fromthe psychiatric evaluation or history from otherssuggests a high level of suicide risk and a recentacute increase in risk

Transitioning Over to Child Protective Reporting….

We are all aware of the procedures for reporting child abuse/neglect. None of this has changed and it is relatively the same across the

nation.The issue is Specific Information Needed

When Reporting

Specific Information Needed When Reporting Physical Abuse

● Identifying Information● Description of injury, location, instrument,

size, shape?● Punched, slapped, open or closed fist?● Frequency?

Specific Information Needed When Reporting Physical Neglect

● Weight change?● Bleeding/infestation of lice?● If you have done a home visit: exposed

wiring, broken windows, rat/roach infestation, maggots, human/pet feces

Specific Information Needed When Reporting Medical Neglect

● Has the parent been notified and been given the opportunity to get help/treatment?

● Who is the family doctor (phone number) listed on the emergency card?

● Does the child take medication at school? Who is the prescribing doctor?

● How is daily functioning impaired?Not likely to be assigned: lack of medical treatment that does not pose risk of serious harm

Specific Information Needed When Reporting Neglectful Supervision

● Are latchkey kids waiting inside or outside of the home?● Do they know what to do in case of an emergency?● Do they have access to a phone/neighbor?● Level of functioning, special needs, or behavioral

concerns?● Are they watching younger siblings?● Are they home alone?

Not likely to be assigned: latchkey kids age 6 and older, delinquent behavior by child age 10 and older, reportedly dangerous animals present but no history of injury to the child

Priorities for Investigations

● Priority 1 (immediate and within 24 hours)

● Priority 2 (within 72 hours)

The Agency assesses and determines the level of risk as it related to possible harm to the child. The Agency has its own assessment tools.

References and Resources for this Portion of the Presentation

http://psychiatryonline.org/content.aspx?bookID=28&sectionID=1673332#56073

http://www.biomedsearch.com/article/Death-throes-professional-liability-after/131605687.html

http://www.stopasuicide.org/docs/APASuicideGuidelinesReviewArticle.pdf

http://www.dfps.state.tx.us/Contact_Us/report_abuse.asp