1. It would NOT be necessary to file a Suspected Child Abuse Report if Anthony told you he
a. Had a sexual relationship with his brother's classmate because he felt intimidated by him
b. Had oral sex with his brother’s classmate
c. Sustained any kind of physical injury after a fight with his brother
d. Had any sexual contact with a 13-year-old friend
e. Any of the above would require filing a report
B is correct. Refer to the document Mandated Reporting of Child Sexual Abuse. Any sexual activity involving someone under 18 is reportable if there is evidence of coercion or exploitation. Prior to a case law decision in April 2013, the correct answer would have been E. Before that decision, the child abuse reporting laws treated consensual and non-exploitive “sexual intercourse” differently than consensual and non-exploitive oral sex, anal sex, or penetration with an object. The latter activities might be engaged in more often by same-sex couples, since sexual intercourse by definition is only physically possible for opposite-sex couples. These activities used to mandate a child abuse report if anyone under 18 was involved, whereas sexual intercourse with a 15-year-old was only reportable if the partner was over 21. Since the April 2013 decision, these activities are treated the same as sexual intercourse. It is criminal, but not necessarily reportable, for a person over 18 to have sexual intercourse with anyone under 18, but what is criminal is not always reportable under the child abuse reporting laws.
It would be legal to see Anthony without telling his parents if
a. It appears his parents might harm him if they knew he was in therapy and why he was there
b. His main reason for therapy is to discuss concerns about STDs
c. He does not want his parents to know he is having problems
d. He does not want his parents to know he is gay
e. He is mature enough to participate intelligently in therapy.
E is correct. Refer to the document Consent to Treat Minors. As of January 2011, the only legal criteria for allowing a minor over 12 years of age to consent to his/her own mental health treatment is that, in the therapist's opinion, the minor is mature enough to participate intelligently. However, the best clinical practice in most situations is to attempt to obtain parents' or guardians' consent to treatment and even give them access to the therapy records if they request it. Often in working with adolescents where parents are cooperative and want their child to feel free to be self-disclosing, a therapist can obtain an informal agreement that the parents will not look at the records or ask about the content of the therapy. In Anthony's case, allowing him to consent to his own treatment, might help protect him from prematurely disclosing his sexual orientation to parents who might react in a way that is unsupportive or even abusive.
3. To help with Emily’s concerns about Joan’s plan to move and custody laws outside California, it is within the scope of practice for an MFT or LCSW to
a. Advise her to get a restraining order
b. Advise her to make a written contract with Joan agreeing to keep Justin in California
c. Offer her a referral to an attorney who is knowledgeable about laws affecting LGBT families
d. Discuss ways to communicate with Joan that might de-escalate the conflict
e. Both C and D
E is correct. Giving legal advice is outside the scope of practice for an MFT or LCSW, but helping a client improve relationships through better communication is not. Appropriate, culturally sensitive referrals are part of supporting a client’s overall welfare.
4. Who can give legal consent to Justin’s treatment with you?
a. Emily and Joan must both give consent
b. Either Emily or Joan can give consent, without agreement from the other
c. Justin can consent to his own treatment if getting consent from a parent would endanger him
d. Justin’s grandparents can give consent if he is going to be living with them soon
e. Emily and Joan cannot consent to Justin’s treatment without permission from the sperm donor who is his biological father
B is correct. Refer to the document Consent to Treat Minors. As an adoptive parent, Emily has the same rights as Joan when it comes to bringing Justin in for treatment. It is not legally necessary to get consent from both parents, but clinically it often considered best practice to do so. C would be true if Justin were over 12 years old.
5. In considering Alex’s safety and welfare, a therapist should be concerned about
a. Possible domestic violence
b. Medical issues related to starting or stopping hormones without an MD’s approval
c. The risk of a depressive or manic episode
d. Readiness for hormones and/or surgery for transition
e. All of the above
E is correct. Warning signs of all of the above appear in this vignette.
6. If an MFT or LCSW wanted to help Alex obtain hormones from an MD and wanted to follow the WPATH Standards of Care, the therapist would need to
a. Explore further whether Alex’s wish to transition was her own desire or her boyfriend’s
b. Write a recommendation letter omitting the mental health diagnosis
c. Get a second recommendation letter from a therapist with a doctoral degree
d. Require Alex to dress in a more feminine manner for at least three months
e. All of the above
A is correct. Refer to the document WPATH Standards of Care. The psychiatric diagnosis is a part of the recommendation letter. A second letter is only required for genital surgery. The Standards of Care recommend a minimum of three months of psychotherapy or living that long as the desired gender. Dress is only one factor in the gender someone is presenting to the world. In this complex case, whether Alex is appearing in public as female or not, it might be negligent and therefore unethical to assess Alex’s readiness for transition without psychotherapy.
7. A therapist would need to file a mandated report with Adult Protective Services if Martha
a. Is physically attacked or threatened by her son-in-law
b. Wants to move but has trouble finding affordable housing
c. Is being financially exploited by the way her daughter manages her bills
d. Goes to her daughter’s church and encounters disapproval for having had a long-term same-sex partner
e. A or C
E is correct. A mandated report means a therapist MUST make the report, at the cost of the client’s confidentiality, whether or not the client agrees. While Adult Protective Services might be helpful with referrals for an adult over 65 who has financial and housing problems, these conditions do not mandate a report. Physical abuse, intimidation, and fiscal abuse are all reportable. Adults of any age are free to choose their religion and religions are free to espouse opinions, even hurtful ones, about the way people live.
8. It would be both legal and ethical for a therapist to help Martha by
a. Giving her legal advice about her rights regarding inheritance and Social Security
b. Offering to be her payee for Social Security
c. Referring her to an attorney who is knowledgeable about inheritance laws and has experience with surviving members of same-sex couples
d. Reducing her fee so she can afford to pay for therapy without her daughter’s help
e. C and D
E is correct. Legal advice is outside the scope of practice for an LCSW or an MFT. Being someone’s payee while being her therapist would be an avoidable and most likely harmful dual relationship. Referrals to other professions are appropriate and often needed to enhance the client’s safety and welfare. While therapists are not obligated to reduce fees for clients with financial problems, there is no conflicting legal or ethical obligation that prevents a therapist from extending this kindness, unless the therapist’s fee structure is discriminatory, e.g. offering fee reductions only for women or only for men.
9. In working with Helen, it would be prudent to
a. Be as discreet as possible when calling her home, and ask her how you can contact her in a way that will keep her confidentiality
b. Discuss her wish to refer her friend to you, to determine whether there could be any conflict of interest
c. Assess her support system and refer her to hot lines, groups, LGBT centers, and other places where she can get information and support about coming out
d. Listen with empathy and neutrality, without trying to influence her decision about her sexual identity or her marriage
e. All of the above
E is correct. C and D are about helping Helen’s overall well-being and making it likely that she will engage in and benefit from therapy. Therapists avoid conflicts of interest wherever possible, and whether one exists with Helen’s friend would depend on the depth and direction of their friendship (is this the friend Helen was attracted to? a best friend? a casual acquaintance she rarely sees?), the therapist’s theoretical orientation, and Helen’s comfort level about sharing her therapist (which she might not be express if the therapist does not ask). Confidentiality is critical in every case but has particularly important consequences here because Helen is exploring feelings that may affect her marriage and that she is not ready to share with her husband.
10. The therapist in Frank’s case has a duty to
a. Warn Frank’s prospective sexual partners that he might infect them with HIV
b. Get consultation to manage countertransference if he/she feels physically attracted to Frank
c. Give Frank the BBS publication Professional Therapy Never Includes Sex
d. Determine whether there is a practical way to maintain appropriate boundaries regarding the gym membership, and if not, either give up that gym or give Frank a referral
e. B and D
E is correct. Tarassoff law or the “duty to warn” prospective victims of serious physical harm, which overrides a client’s right to confidentiality, has never been applied to HIV, not even during the time when the risk of dying from the virus was great due to the lack of medical treatments available. A couple of common senses reasons for this might be that 1) consensual sex between adults presumably involves each of them making his/her own assessment about whom to trust and what kinds of sexual practices to engage in, and 2) unprotected sexual contact with someone who has HIV does not necessarily lead to becoming ill or even contracting the virus. Therapists are obligated to give clients the BBS publication only when they learn that a client’s past or present therapist(s) may have been sexually inappropriate. Therapists avoid sexual relationships with clients and are ethically obligated to manage countertransference of any kind through consultation and other means so that they do not harm or exploit clients. The gym membership may be handled differently by different therapists. For example, a therapist in an urban area would be hard pressed to argue that this dual relationship was unavoidable, whereas a therapist in a small town might have to share many local resources with clients and their families. And a therapist who plans to do long term depth work with Frank might approach this differently than a therapist who will be seeing him short term and using methods that tend to engender less transference. The bottom line is that the therapist should make every possible effort to avoid disrupting the trust and boundaries needed for a therapeutic relationship.
Law and Ethics with an LGBT Focus Part Two