The therapist engaged in a dual relationship the their optomotrist that led to a conflict of interest. There was no documentation of the dual relationship. Following a domentation review, the board found several deficiencies, leading them to futher audit the therapist’s documentation. Below are some items that are frequently found missing in client files:
Treatment plans fail to include one or more treatment methods.
Informed consent failed to include notification of supervision.
Informed consent and/or treatment plans not signed by the therapist and/or client.
Informed consent failed to include clients right to refuse treatment, risk of telehealth therapy, client right to be informed of fees, payment policies, client right to participate in treatment planning, general procedures to be used in treatment,
Progress notes did not include the procedure and location. In our notes, this should always be the first statement (writer met with client in-office for an individual 60-minute counseling session)
Please check out our Informed Consent sample if you are interested in how we’ve worked to meet the board’s expectations.
The therapist told their client that they document in a manner that would be useless to the courts. They further told their client that know how to stay out of court. When ultimately subpoenaed, they testified, and have no forensic training. They made recommendations and provided opinions about ADHD medication and provided diagnostic impressions of the complainant (one of the parents of the client) by labeling them as “possibly bipolar” and having “narcissistic tendencies.” Lastly, the therapist had several paid invoices in the file without corresponding documentation.
It is common for board complaints to be initiated when a therapist is involved in high-conflict relationships, such as a divorced parent. For instance, In high-conflict divorces, therapists must meticulously maintain professional boundaries while managing the expectations and demands of both parents, who may have opposing goals or perspectives regarding therapy. Therapists must avoid dual relationships that could impair their objectivity and professionalism. For example, acting as both a child's therapist and a mediator between disputing parents can lead to conflicts of interest.
It is important to minimize opinions about others whom you have not assessed, especially other family members. While therapists may recognize patterns of behavior consistent with narcissistic abuse in descriptions provided by their clients, directly diagnosing or labeling individuals who are not our clients is generally avoided due to ethical, legal, and professional considerations. The primary goal remains to support the client's well-being, safety, and informed decision-making within the therapeutic relationship.
As therapists, our role encompasses providing clients with general, educational information about how medications may play a role in their mental health care. This entails discussing the typical functions and potential side effects of psychiatric medications, and the importance of adhering to the prescribed treatment plan. It's vital to encourage clients to communicate openly with their prescribing healthcare providers about their medication experiences, ensuring any specific questions or concerns are addressed by those qualified to give medical advice. Directing clients back to their prescribers for tailored advice reinforces our support for an integrated approach to mental health care, maintaining our professional integrity by adhering to our scope of practice. This balanced approach underscores the value of a multidisciplinary treatment plan, highlighting our commitment to holistic client care.
The therapist refused to provide clinical records to a parent, incorrectly interpreting the court agreement about medical decision-making and records, believing the father had sole decision-making. Additionally, the minor client engaged in self-harming behaviors and there was no documentation of a risk assessment or safety plan. The self-harming behavior was not reported to either parent. After reviewing documentation, there were several deficiencies found.
The therapist failed to respond to a parent's requests for medical records, citing an inability to verify the requester's identity and legal relationship to the client. However, court documents indicated both parents had equal rights to access their child's medical records. This situation underscores the importance of understanding and adhering to custody agreements and state laws governing parental access to a minor's health information. Failing to provide records upon a reasonable request can violate confidentiality norms and parental rights, leading to board complaints and legal issues.
While self-harming behavior does not necessarily imply suicidal ideation, it is considered a risk factor and should initiate a risk assessment and possible safety plan. When a client reveals self-harming behaviors, therapists are ethically and professionally obligated to assess the risk of suicidality and implement appropriate interventions, including safety planning and involving the client's support system, especially in the case of a minor. Failing to adequately assess and document the client's risk poses a danger to the client's health and safety and can be seen as neglect
A history of self-harm significantly elevates the likelihood of suicide, with studies finding a strong association between previous self-harm incidents and subsequent suicide attempts or completions. Meta-analyses and systematic reviews consistently identify self-harm as a critical risk factor, emphasizing the need for vigilant assessment and intervention strategies for individuals who have engaged in self-harm behaviors. It's important for professionals to recognize self-harm as a significant marker of distress and a predictor of future risk, including suicide.