ETHICS FOR TEXAS LPCs: CONFIDENTIALITY
Confidentiality is generally considered a cornerstone of the
doctor-client relationship. (Alban, A., 2007) Many counselors assume that
mental health treatment is most likely to be successful when the client has a
trusting relationship with the clinician. (US Department of Health and Human
Services, 1999, citing Sharkin, B., 1995) People tend to reveal much of their
private selves in the course of receiving counseling. Trust that clinicians and
institutions will preserve client privacy is necessary to maintain the value of
mental health services. Laws that protect confidentiality attempt to preserve
this trust, so that people will be more likely to benefit from mental health
services such as counseling. With trust in confidentiality, people are more
likely to pursue counseling, are more likely to afford the level of care that
they need by utilizing their insurance and other benefits, and are more likely
to divulge information that is needed to ensure effective treatment. In
addition to the needs of individuals, confidentiality laws serve the interests
of family members, employers and society in general, by helping to reduce the
impact of mental and emotional disorders and personal problems.
These laws protect as private information both the fact that an
individual has sought mental health treatment, and the disclosures that are
made during treatment. (Ibid) Confidentiality
laws can also serve to protect the client or other family members and even the
counselor from the danger that may result when a violent individual learns that
someone they have intimidated is seeking support, or when that individual
learns of the identity of the counselor. These laws help to protect individuals
from problems such as social stigma, and workplace and housing discrimination.
Legislatures and the justice system have given considerable
attention to issues concerning the role of privacy in health care over the last
three decades. While the legal right to privacy has been at issue most
frequently in procreation and end of life decisions, it is well established as
being of great importance in mental health services. (Ibid)
The right to privacy itself, in its most abstract form, has its
genesis in the fourth amendment of the Constitution. (Ibid)
The confidentiality of counseling clients includes the question of
whether they are participating in mental health services. Counselors must
refrain from confirming or denying that any individual is or has been a client,
so long as there is no legal exception to confidentiality. All details of the
verbal and written communications in the course of counseling, assessment, testing, reporting and other communications are also
protected as private information.
is not absolute: In certain types of circumstances, LPC’s have discretion, or
even a legal duty, to disclose confidential patient information. However,
casual disclosures appear to be rare. According to Pope, et al., "[f]ew
psychologists blatantly breach the confidentiality of their clients."
(Pope, K. S. & Vasquez, J. T., 1998) More often, they note, client
confidentiality is breached "informally" or
"unintentionally." (Ibid) Citing the results of one study, they
report: "About three[-]fourths discuss clients –
without names – with friends. Only 8.1% discuss clients – with names – with
friends." (Ibid) However, they also add: "Surprisingly, over half
(61.9%) have unintentionally disclosed confidential data." (Ibid)
As an Aspect of Informed Consent
Clinicians routinely provide information regarding confidentiality
as an aspect of informed consent. The issues of confidentiality equate to risks
and rewards that the client should knowingly choose when entering therapy.
There are risks that confidentiality may be breached due to legal
responsibilities placed upon the therapist, or breached illegally through an
error or an intentional act. Legal and procedural measures to preserve confidentiality
afford protection, but not certainty.
Privilege: Not Exactly
Confidentiality of medical information is a right that citizens
hold. This right imposes upon therapists a duty to preserve the privacy of
their clients. When another duty competes with the counselor’s duty to preserve
client privacy, the counselor must assert that one duty is a more important
obligation than the other.
For example, if an attorney subpoenas a clinical record, the
counselor usually must assert that his or her duty to preserve client privacy
is more important than the duty to provide the court with confidential client
information. This is the assertion of privilege; that is, asserting that one
duty has a privilege over another. By asserting privilege, the counselor is
fulfilling the responsibility of “holding” the clients
right to privacy.
§ 681.41(e)(4), LPC’s are required to notify patients,
in writing and before or during the initial consultation, of any applicable
limits on patient confidentiality. Texas
places few limits on patient confidentiality. However, circumstances do exist
that may require an LPC to breach client confidentiality, at least to a limited
degree. Informed consent requires that clients be made aware of such
on confidentiality include, but are not necessarily limited to, four major
contexts: billing and insurance issues; situations involving a client who is
minor or an incapacitated adult; situations where risk of harm exists; and when
an LPC discovers that a client is already under the care of another provider.
Every client should receive advance notice, in writing, of these and any other
possible limits on confidentiality. (Limits, or exceptions, to confidentiality are
discussed in some detail in the Exceptions to Confidentiality section below. An
in-depth exploration of confidentiality and disclosure issues is the subject of
a separate course.)
regard to billing and insurance issues, an LPC should advise the client of the
types of information that must be released to ensure payment, and which
entities (or types of entities) entitled to receive such information. The LPC
should also ask the client whether she is under the care of another counseling
provider; and advise the client that, if so, the LPC must inform the other
a client who is a minor or an incapacitated adult, the LPC should inform the
client of the types of situations that may require her to breach
confidentiality, such as obtaining consent from a parent or guardian for
certain types of treatment. To the extent possible, the LPC should present such
information in a way that the client can understand.
regard to risk of harm, an LPC should advise clients that confidentiality may
be breached in a variety of contexts: where the LPC has reason to believe that
a child is being abused (whether the client is the child or the suspected
abuser); where the LPC has reason to believe that the client poses a risk to
others; or where the LPC has reason to believe that the client poses a risk to
herself (e.g., risk of suicide).
statutes provide very few express limits on confidentiality, and thus, very
little legal protection for LPC’s who breach it. LPC’s should review § 611 of
the Texas Health and Safety Code carefully before breaching client
confidentiality to ensure that such a breach falls within protected limits.
Insurance companies, including managed care companies, have the
responsibility to protect privacy. This includes having systems and policies in
place to accomplish such protection.
Clients are not always aware of what information will be sent to
insurers, particularly where managed care policies include reviewing clinical
information in order to determine whether to authorize additional treatment or
a change in level of care. Informed consent dictates that counselors provide
enough information about their relationship with the insurer that the client
can be make informed choices regarding their confidentiality.
For example, a client may not want certain diagnoses to become
preexisting conditions affecting their insurability after a change in
employment (and insurance policies) that could take place in the future. In
some cases, clients may prefer to pay privately or limit the focus of therapy
based on this information. In any case, the counselor should attempt to limit
the information provided to only that which is necessary to conduct business
with the insurance company, and only in so far as the release of information
authorized by the client permits. (ACPA, 2003)
of patient mental health records is governed by Title 7 of the Texas Health and
Safety Code, Sec. 611, and is the subject of a separate course. However,
certain provisions of § 681.41 relate to confidentiality and will affect how
LPC’s handle specific types of situations. And under § 681.41(x), an LPC has an
affirmative duty to "comply with the requirements of Texas Health and
Safety Code, Chapter 611, concerning the release of mental health
under § 681.41(e)(4), LPC’s are required to inform new
patients in writing, before or at the time of the initial consultation, of the
limits of patient confidentiality. In Texas,
there are few such limits, and for the most part, limiting confidentiality
occurs at the therapist's discretion. As a practical matter, however, LPC’s may
find that complying with standards of professional practice and ensuring client
welfare may require them to exercise that discretion and breach patient confidentiality
under certain circumstances. In addition, to the extent that such exceptions
are not mandatory, LPC’s who choose to breach client confidentiality under such
circumstances, however urgent, may expose themselves to risk of civil
liability, professional discipline, and possibly even criminal penalties.
other statutes affect how LPC’s should apply the requirements of § 681.41(e)(4). These other statutes are reviewed briefly in the
ensuing subsections; they are discussed in depth in a separate course.
the most part, such information is likely to concern billing issues, and §
681.41(r)(2) indirectly provides for such disclosure
where the client is a minor.
(r)(2) is intended primarily to ensure that clients
receive full explanations of their treatment and the charges for that
treatment. If a client makes a written request for such an explanation, the LPC
must provide, "in plain language, a written explanation of the types of
treatment and charges for counseling treatment intervention previously made on
a bill or statement for the client." However, the LPC is required to
provide such information in two other situations: 1) where the client is a
minor, and a parent or guardian makes such a request; or 2) where the client is
an incapacitated adult and such a request is made by the client's guardian.
"This requirement applies even if the charges are to be paid by a third
The Health Information Portability and Accountability Act (HIPAA)
is the first federal privacy standards act intended to protect client’s medical
records and other health information in the possession of health care
providers, including health plans. Congress enacted HIPAA, also known as the
Kennedy-Kassebaum Act, in 1996. Developed by the Department of Health and Human
Services (HHS), it took effect in 2003. Also known as the Privacy Rule, HIPAA
provides clients with access to their medical records and gives them more
control over their personal health information. The Act is intended to
establish a nation-wide floor of privacy protections, meaning that states may
maintain or establish more stringent laws without being invalidated by HIPAA.
(US Department of Health and Human Services, 2000) HIPAA also protects
employees who change jobs and protects the rights of people with health
insurance. It includes significant privacy, confidentiality, reporting and
compliance requirements. (Dauner,
C. D., 2001)
HIPAA is also intended to make health insurance coverage more
available. It does this through means such as improving the transmission of
electronic records and providing improved privacy of health and medical
HIPPA rules apply to counselors who transmit records
electronically in carrying out financial transactions or administrative
activity such as claims submission. This includes Internet or email
transmission, and the use of electronic media such as CD's. Faxing and
electronic data storage are not included. (Alameda
Association, 2003). The individuals and organizations to which HIPPA
applies are referred to as “covered entities.” HHS provides a great deal of
information, including answers to common questions at www.HHS.gov/ocr/hipaa.
(Ibid) It is better known as a means of regulating corporations such as health
plans, hospitals and pharmacies that previously were not as accountable for
protecting client confidentiality. However, counselors in solo private practice
stand to benefit by adopting HIPAA compliance, particularly regarding informed
consent and maintaining separate psychotherapy notes.
HIPAA is respectful of state law when it comes to confidentiality
and disclosure of health information, referred to in the law as private health
information (PHI). As you would expect, it requires written authorization for
all disclosures of PHI, but it exempts "treatment, payment or
operations" (TPO), such as billing and training.
The law distinguishes between "use" and
"disclosure" of PHI. Use refers to transfer of information within an
organization that is a covered entity. Disclosure refers to release of
information outside of the organization or the counselor's practice.
Counselors do not need a separate authorization for
"uses" of PHI (as you’ll recall, that is personal health information)
as mentioned above. HIPAA lists the following as TPO (again, that is treatment,
payment and operations) "uses.”
Use by the originator of
the psychotherapy notes for treatment
Use or disclosure by
counselors for their own training programs in which students, trainees, or practitioners
in mental health learn under supervision to practice or improve their skills in
group, joint, family, or individual counseling
disclosure by counselors to defend themselves in legal actions or other
proceedings brought by their clients. (Alameda
Counselors are to provide their clients with a notice that
describes the counselor's privacy practices by the first appointment. The
counselor must make a good-faith effort to get written acknowledgement from
clients indicating that they have received this notice, and the notice must be
posted in the counselor's office.
For specific authorizations to release information, that is,
releases that are not covered by the initial TPO uses release, the client must
sign a release form. HIPAA has specific criteria for such a form.
2003, the United States Department of Health and Human Services (HHS) also
issued new guidelines that apply specifically to psychiatrists. Because of
HIPAA, psychiatrists now must maintain two sets of records for each patient: 1)
regular medical records; and 2) separate psychotherapy notes. Under HHS
regulations, notes detailing a conversation between psychiatrist and patient during
a consultation are classified as "psychotherapy notes."
to lawyer Dan Willick, the purpose of the new regulations is to protect patient
confidentiality in an era of managed care:
psychiatrists start keeping medical records and psychotherapy notes together,
there is a heightened chance that the notes from therapy sessions will be
disclosed to a third party. Health plans and insurers cannot require the
disclosure of psychotherapy notes as a condition of enrollment or treatment,
but they can require disclosure of a patient’s medical records. (Kupersanin, E., (2001)
One of the protections for the mental health information of
clients afforded by HIPAA lies in HIPAA’s designation and use of psychotherapy
notes. HIPAA protects psychotherapy notes from the blanket release that allows
medical information to be used for administrative purposes. It requires that
the notes be protected from view by anyone other than the counselor and anyone
to whom the records are specifically authorized for release. Its protections
for psychotherapy notes include the provision that they be separate from the
client’s main record. This helps ensure, for example, that the psychotherapy
notes will not be accessed by a clerk out of curiosity. (US Department of
Health and Human Services, 2000) (US Department of Health and Human Services,
2003, part 4)
HIPPA defines psychotherapy notes, and specifies what must be
placed in the main record and never put in the psychotherapy notes. It also
requires that the notes be maintained separately from the main record. (Ibid,
parts 1 and 7) The definition of psychotherapy notes as pertaining to the
“contents of conversation” is a very limited definition because it is part of a
design to both maintain a viable primary record, as well as prevent or limit
distribution of the most private information.
Authorized Release of Information
The client may consent to a release of confidential information
for many reasons, the chief of these being the provision of information to
another care provider, such as a psychiatrist or new counselor. Other reasons
include providing information that verifies compliance with the requirements of
an outside entity such as the client’s probation officer or employer.
Under HIPAA, an organization that provides clinical services may
allow staff access to client information in order to maintain records,
supervise clinicians, do case management and other tasks. Similarly, an
individual counselor may reveal information to a person or organization that
provides administrative services such as billing. In all cases, the information
must be limited to what is necessary to provide the service. The people who
have access to that information must treat it as confidential medical
The counselor must consider the welfare of the client, even when
the client has authorized or demanded a disclosure. If the counselor is
convinced that the disclosure is not in the best interest of the client, then
the counselor may need to refuse to cooperate with the disclosure and attempt
to dissuade the client from making such a disclosure. Consider the example of a
client who thinks that providing information to a physically abusive spouse
will help the spouse develop more empathy. In such a case, the counselor would
have to consider whether the disclosure might actually worsen the danger.
Compulsory Mental Health Treatment
Additional confidentiality issues arise when there is compulsory
mental health treatment. This occurs when people are compelled by organizations
such as courts or employers to seek mental health assessment and treatment for
various reasons. A court may compel an individual who has been convicted for
driving under the influence of alcohol or drugs to undergo a substance abuse
and mental health assessment. The court may require a period of time during
which the client must provide urine screens in order to test for evidence of
current substance abuse. A person failing to comply with the court orders can
suffer legal consequences that may include imprisonment.
Private entities such as employers may compel people as well. For
example, many employers have policies that allow them to suspend the
disciplinary process. This can prevent the employee from being fired so long as
the employee cooperates with a mandatory referral process. This process can
include a referral to the company employee assistance program (EAP), and can
require compliance with the recommendations of that program. Ultimately, the
employee must improve his or her functioning within a period of time that does
not constitute a hardship for the employer. (Yourell, R. A., 2007)
The counselor must deal with contractual obligations with the
organization as well as abide by the ethics and laws of confidentiality
pertaining to the client. Generally, in a compulsory referral, the client will
release the counselor to provide certain limited communications with the
referring organization. Usually, the client can terminate that release at any
time. This normally means that the referring organization will consider the
client to be “out of compliance” with the mandatory referral, and impose
whatever disciplinary process is slated to occur in the absence of such
Counselors can learn more about compulsory referrals through the
confidentiality course, or by gaining EAP (employee assistance professional)
The counselor must respond to a subpoena, because subpoenas have
the force of law. Attorneys are officers of the court, and require information
to fulfill their duty in cases. Subpoenas are generally issued during the
discovery phase in preparing for trial. Attorneys generally cast a wide net in
seeking information; not knowing in advance what information will be of use.
(Alban, A., 2007)
There are several ways for the counselor to uphold his or her
responsibility to protect client privacy. It is very important to plan the
response to a subpoena with the help of an attorney, because there are too many
legal variables. You may need to attempt to have the subpoena quashed (usually
on a technical ground), modified, or even attempt to negotiate with the party
issuing the subpoena. (Ibid)
Other Requests for Information or Confidentiality
Counselors may experience requests for information about clients
or people believed to be a client from outside individuals or organizations.
These may include family members, attorneys, journalists, law enforcement
officers, neighbors or other parties.
A straightforward way for the counselor to assert privilege is to
state, “I can neither confirm nor deny that the individual is a client, and I
cannot divulge confidential information regarding anyone who is a client.”
This statement is true even if there is public knowledge or the
person or organization knows of the treatment. It is true even though the
client is speaking publicly about the treatment. It is even true when there is
an exception to confidentiality, such as child abuse, because exceptions to
confidentiality only allow the information to go to specified people or agencies
under specific circumstances.
An individual who contacts the counselor about someone he or she
believes to be a client may request that the conversation with you be kept from
the client. The counselor cannot make such a commitment because it may not be
in the best interest of the client.
Unsolicited Information about the Client
An individual may contact the counselor with information about the
client. The counselor may consider it in the best interests of the client to
accept the information, but should contact the client promptly to disclose that
this activity has taken place.
has its limits, and Texas
law spells out several exceptions to client confidentiality. They are threat of
harm to self or others, certain lawsuits, a court order, detention of a
mentally disordered person for evaluation, and reasonable suspicion of abuse of
a minor or dependent adult.
and Administrative Proceedings
may disclose confidential client information in certain types of judicial or
administrative proceedings. As a general matter, such disclosure is not
mandatory; rather, it is a matter of the counselor's discretion. Such
disclosure is covered under Title 7 of the Texas Health and Safety Code, § 611,
and is discussed in depth in a separate course.
of client confidentiality may arise in two other contexts: 1) harm to others,
and 2) harm to self. However, the degree to which an LPC is permitted to breach
confidentiality in order to prevent harm varies from state to state. Depending
on the jurisdiction, such a breach may be mandatory, discretionary, or
prohibited; it may also vary depending on whether the threat of harm is to the
client herself or to third parties. In Texas,
it is discretionary, at least theoretically. Under § 681.41(m), "[a]
licensee may take reasonable action to inform medical or law enforcement
personnel if the professional determines that there is a probability of
imminent physical injury by the client to the client or others or there is a
probability of immediate mental and emotional injury to the client." And
under subsection (n), an LPC must "take reasonable precautions to protect
individuals from physical or emotional harm resulting from interaction within a
group or from individual counseling."
LPC’s should consider carefully any decision to breach client confidentiality
to prevent harm, particularly to third parties. Under Texas law, it is likely that greater
protection exists for LPC’s who breach client confidentiality to prevent the
client from harming herself than for those who do so to prevent the client from
harming others. Disclosure in the context of both harm to others and harm to
self is reviewed in depth in a separate course.
Harm to Others
states follow the precedent case law (Tarasoff v. Regents of the University of
California, 1976) and subsequent legislation in California. In Tarasoff, a therapist had
been treating a patient who had become obsessed with a female student and had
told the therapist that he had feelings of wanting to kill her. The therapist
informed local law enforcement officials that he believed a threat of physical
harm existed, but he did not advise the woman herself. The police visited the
patient and determined that there was no imminent threat. Several weeks later,
the patient killed the young woman.
student's parents sued the therapist for negligence, arguing that he had a duty
to warn a third party who was the object of a patient's threat (i.e., their daughter).
The therapist argued that restrictions on patient confidentiality prevented him
from warning the woman. The California Supreme Court disagreed, finding that a
therapist does have a duty to warn an identifiable third party of a specific
threat of harm made against her by a patient.
Texas courts, however, have not adopted
Tarasoff. Indeed, as recently as 1998, in Thapar v. Zezulka (Thapar v. Zezulka,
1999), the Texas Supreme Court ruled that, even where a patient makes a
specific threat against a readily identifiable third party, a mental health
professional has no duty to warn the third party of that threat.
Thapar, a therapist treated a patient on both an inpatient and outpatient basis
for alcohol abuse, post-traumatic stress disorder, threats of suicide, and
paranoid delusions related to his stepfather. During one hospitalization, the
patient admitted to his therapist that he "fe[lt]
like killing" his stepfather, although according to her notes, he also
told her that he had "decided not to do it." (Ibid) After seven days,
he was discharged; within a month, he shot and killed his stepfather. The man's
widow sued the therapist for the death of her husband, alleging that the
therapist was negligent in "misdiagnosing" the patient, in discharging
him, in not committing him involuntarily, and in not ensuring that he took his
medications after being discharged, as well as in not warning the patient's
stepfather of the threat.
Texas Supreme Court noted that in 1979 (three years after the California Supreme
Court's ruling in Tarasoff), the Texas legislature had considered issues of
patient confidentiality, and had enacted an extremely restrictive statute
barring any disclosure outside the context of certain very limited exceptions.
The court found that, under the state's patient confidentiality law, no
exception existed that would have permitted the therapist to warn the patient's
stepfather. Had she done so, she would have risked professional disciplinary
action and a possible malpractice lawsuit by her patient. The court held that
there is no legal duty to engage in an activity that is prohibited by statute, and that “[i]mposing a legal duty to warn third
parties of patient[s’] threats would conflict with the scheme adopted by the
Legislature... ” (Ibid)
language of § 681.41(m) provides that an LPC "may take reasonable action
to inform" of an imminent threat of harm to others. In other words, taking
such action is discretionary on the part of the LPC; it is not mandatory.
Moreover, the subsection specifies that an LPC may take such action "to
inform medical or law enforcement personnel"; it says nothing about
informing third parties themselves. Thus, if an LPC believes that a patient
poses a threat to a third party, she may inform medical or law enforcement
personnel, but she may not inform the person who is the subject of the threat.
Finally, the language of this subsection limits such disclosures to
circumstances in which there is a "probability of imminent physical injury
by the client... to others." In other words, the threat must meet three
requirements: It must be 1) probable; 2) imminent; and 3) it must involve
physical injury. Subsection (m) does not provide for such disclosure if the
threat of harm to others involves mental or emotional injury.
Harm to Self
noted above, § 681.41(m) also governs breach of confidentiality in the event of
a client's threat of harm to himself. Again, the decision whether to breach
confidentiality in this situation is discretionary. However, under the
subsection's language, there is arguably a stronger case for a duty to
"inform medical or law enforcement personnel" in the event of a
client's threat to harm himself than in the event of a client's threat to harm
a third party.
regard to threats of harm to third parties, the statutory language limits
disclosures to situations involving a threat of physical injury. With regard to
a client's threat to harm himself, however, an LPC has discretion to
"inform medical or law enforcement personnel" if there is a
"probability if imminent physical injury... to the client" or if
there is a "probability of immediate mental or emotional injury to the
determining whether to disclose such a threat of injury, two requirements must
be met. However, LPC’s should also note that the requirements differ depending
upon the type of injury. If the threat is of physical injury, the threat must
be both 1) probable and 2) imminent, For a threat of
mental injury, the threat must be 1) probable and 2) immediate. Likewise, for a
threat of emotional injury, the threat must be both 1) probable and 2)
Neglect, or Exploitation of Children or Elderly Persons
of harm to others that involve child abuse or neglect fall into a separate
category, covered under Title V of the Texas Family Code, § 261. Under § 261,
an LPC who suspects that child abuse is occurring has a duty to report it
within 48 hours of the LPC's first suspicion. Such reports must include the
child’s name and address; the name and address of the child’s parent(s) or
guardian(s); and any other “pertinent information." Reports may be made to
a variety of state entities, including:
local or state law enforcement agency;
relevant governmental department, if applicable;
relevant state licensing agency or other administrative body, if applicable;
child protective agency designated by a court; or,
instances involving abuse of one child by
another child, the Texas Youth Commission.
a general matter, LPC’s who breach client confidentiality for purposes of
reporting suspected child abuse or neglect, and do so in good faith, are immune
from civil or criminal liability. These and other applicable provisions of the
Texas Family Code are the subjects of another course.
of harm to others that involve abuse, neglect, or exploitation of elderly
persons also fall into a separate category, covered by Chapter 48 of the Texas
Human Resources Code. Again, as with abuse and neglect of children, LPC’s have
an affirmative duty to disclose such suspicions. Failure to report is a
misdemeanor, and the LPC may be subject to professional discipline.
Sexual Exploitation by
Mental Health Services Provider
final form of harm to others involves sexual exploitation of clients. Under
Title 4 of the Texas Civil Practice and Remedies Code, § 81, if an LPC suspects
that a client is being sexually exploited by another mental health services
provider, she has an affirmative duty to report. Failure to do so is a
misdemeanor, and risks professional disciplinary action. Such disclosure is
discussed in detail in a separate course.
lawsuit may result in a subpoena for client information. A subpoena is not a
court order, and the counselor is obligated to preserve client confidentiality
unless there is an exception or an appropriate and authorized release of
information. The counselor can respond to such a subpoena by stating that he or
she can neither confirm nor deny that any given individual is a client, and
cannot release information from a client record without consent or a court
by Another LPC
confidentiality may also be breached in the event that an LPC discovers that
she is treating a client who is already undergoing treatment with another LPC.
Under § 681.41(l), an LPC "shall not knowingly offer or provide counseling
treatment intervention from another mental health services provider except with
that provider's knowledge." Once an LPC discovers that such a situation
exists, she is required to "take immediate and reasonable action to inform
the other mental health services provider." At a minimum, the LPC thus
must disclose the client's identity and the fact that she has been treating the
client; in the course of resolving the situation in a way that best promotes
the client's welfare, she may also need to disclose specifics of treatment.
However, if such a situation arises, an LPC should take care to disclose as
little as possible. The more information that is disclosed,
the greater the risk of professional disciplinary sanctions or civil
and documentation requirements are covered under § 681.41(o)-(p). Among the
topics that fall into this category are the following requirements:
of accurate records, including (but not limited to) intake documentation,
including assessment, treatment plans, dates of treatment, types of treatment,
complete and relevant case notes, and billing and payment records.
records, including (but not limited to) fee schedules, explanation of services
and applicable fees; documentation of billing and payment history; and
insurance accepted, coverage limits, and associated documentation.
of records, including (but not limited to) retention methods, required length
of retention, differences in retention requirements for adult and child
clients, security and storage issues, and disposal.
for transfer of patient records in event of practice closure, etc.
to record-keeping requirements, including (but not limited to) educational
institutions and governmental entities.
American Psychological Association (APA) has issued model record-keeping
guidelines. (American Psychological Association, 2007) As with all APA model guidelines,
the guidelines make it clear that " They are not
definitive and they are not intended to take precedence over the judgment of
the APA guidelines make clear, client benefit is the most important reason for
maintaining and retaining accurate records. Complete and accurate records make
it possible to track client treatment and progress (or lack thereof), develop
and alter treatment plans appropriately, and ensuring that the client receives
the best possible care. However, complete and accurate record keeping also
benefits the therapist in a variety of ways. First and most obviously, they
help the therapist to ensure proper treatment and promote client welfare.
Second, they help LPC’s ensure compliance with state and professional
regulatory requirements, as well as necessary insurance, benefits, and related
documentation. Third, but by no means least, they help protect LPC’s in the
event of professional disciplinary charges, a malpractice suit or other civil
litigation, or criminal charges.
records that Texas LPC’s must create and maintain are outlined in § 681.41(o).
Under this subsection, an LPC is required to "keep accurate records of the
dates of counseling treatment intervention, types of counseling treatment
intervention, progress or case notes, intake assessment, treatment plan, and
billing information." Content that falls into these categories should be
regarded as the minimum required under the statute: If an LPC's practice
generates other types of patient data that are not specifically itemized in §
681.41(o), it is likely to be prudent to include such information in a client's
formal record. It is also prudent to include a copy of all documentation
provided to a new patient during the intake process, as required under §
guidelines state that, “Records include information such as the nature,
delivery, progress, and results of psychological services, and related fees.”
APA sets forth three kinds of information that the record may include:
in the client’s file:
data (e.g., name, client ID number);
information (e.g., phone number, address, next of kin);
and billing information;
appropriate, guardianship or conservatorship status;
of informed consent or assent for treatment (Ethics Code 3.10);
of waivers of confidentiality and authorization or consent for release of
information (Ethics Code 4.05);
of any mandated disclosure of confidential information (e.g., report
child abuse, release secondary to a court order);
complaint, diagnosis, or basis for request for services;
plan for services, updated as appropriate
(e.g., treatment plan, supervision plan, intervention schedule, community
interventions, consultation contracts).
health and developmental history.
each substantive contact with a client:
of service and duration of session;
of services (e.g., consultation, assessment, treatment, training);
of professional intervention or contact (e.g., treatment modalities, referral,
letters, e-mail, phone contacts);
or informal assessment of client status;
record may also include other specific information, depending upon
responses or reactions to professional interventions;
risk factors in relation to dangerousness to self or others;
treatment modalities employed such as medication or biofeedback treatment;
interventions (e.g., specially scheduled sessions, hospitalizations);
for future interventions;
describing the qualitative aspects of the professional/client interaction;
or summary data (e.g., psychological testing, structured interviews, behavioral
ratings, client behavior logs);
with or referrals to other professionals;
telephone, mail, and e-mail contacts;
relevant cultural and sociopolitical factors.
these minimums, LPC’s have substantial discretion. For example, determining
what information (i.e., the amount of detail) makes patient records on
assessment or consultation is a matter of the individual LPC's professional
judgment. Creating detailed records not only helps the clinician’s
recollection, but also fulfills the needs to transfer detailed information
required for matters such as transfer of care and hospitalization. Also, there
is the concern that the clinician may be vulnerable to malpractice issues
inflamed by inadequate records.
records are covered largely under § 681.41(r), which also addresses billing and
fee-related issues that fall into such categories as scope of treatment and
disclosure. However, the types of documentation that must be provided to a new
patient upon initial consultation, including "fees and arrangements for
payment, are covered under § 681.41(e).
basic requirement of subsection (r) provides that LPC’s "shall bill
clients or third parties for only those services actually rendered or agreed to
by mutual understanding at the beginning of services or as later modified by
mutual written agreement." The language shown here in italics is crucial.
Under subsection (e) of the statute, new patients must be advised of fee and
payment arrangements in writing before or during the initial consultation.
Subsection (f) requires an LPC to notify clients in writing of any change to
any of the information required under subsection (e), and must do so before the
change takes effect. Taken together, the language of subsections (e), (f), and
(r) makes clear that LPC’s must notify clients in advance and in writing of any
modifications to fee agreements and payment arrangements, regardless of when in
the course of the therapeutic relationship such modifications are made.
records also must be accurate. Subsection (r)(1)
requires that billing documents indicate "[r]elationships between a
licensee and any other person used by the licensee to provide services to a
client." Subsection (r)(3) prohibits an LPC from
"knowingly or flagrantly overcharg[ing] a client." Finally, under
subsection (r)(4), an LPC may not submit a bill to a client, insurance company,
or other third-party payor "for counseling treatment intervention that the
licensee knows was not provided or knows was improper, unreasonable, or medically
or clinically unnecessary," although LPC’s are permitted to bill for
appointments a client has failed to keep.
records provide special ethics pitfalls: Failure to maintain them properly may
subject an LPC not only to professional discipline, but also to criminal
liability, which may include state and federal fines, administrative penalties,
and a prison sentence.
regard to retention of records, the key is security: physical security of the
actual records themselves; and security of the records' content (i.e.,
confidentiality). As APA guidelines make clear, LPC’s "have
ultimate responsibility for the content of their records and the records
of those under their supervision." (American
Psychological Association, 2007) As a result, they urge that therapists
"oversee the design and implementation of record keeping procedures, and
monitor their observance." (Ibid)
designing record-keeping and retention systems, LPC’s should keep certain
objectives in mind. Records must be created in a timely fashion, to allow for
inclusion of all necessary data while the information is still fresh in the
LPC's mind. They should be legible and comprehensible to those who must use
them. This may mean typing patient notes to avoid misreading of illegible
handwriting. They should also use terminology that is generally accepted in the
profession, so that, in the event that another professional must use them
(e.g., during a consult) when the LPC is not present to translate, there are no
misunderstandings. For LPC’s who use their own private form of shorthand in
making patient notes, this may require translating those notes into generally
accepted professional terms when reducing them to permanent patient records.
must also be organized in a way that permits timely access and retrieval by
those who must use them. Storage methods vary: Some practitioners continue to
use ordinary paper charts and files; others use only electronic media, which
may include a computer's hard drive, CD-ROMs, floppy disks, etc.; and some use
a combination of paper and electronic media. Whichever method(s) an LPC
chooses, it should be stable, secure, protected from internal damage (such as
computer viruses or file corruption) and external damage (such as fire,
weather, and vandalism), and retrievable. Security measures are discussed
essential issue with regard to retention is availability (i.e., the length of
time that individual records must be retained and produced if necessary). These
standards vary by jurisdiction, and may even vary between federal, state, and
local laws and the requirements of professional licensing bodies.
statutory minimums apply to retention of LPC client records. Length of
retention is covered under § 681.41(p): Adult patient records must be retained
for a minimum of seven years before destroying them. LPC’s must retain the
records of patients who are minors (or who were minors when they began
treatment) for a minimum of seven years beyond the time that the child reaches
of records is necessary for a number of reasons, including transfer of care and
coordination of treatment. § 681.41(y) provides: "A licensee shall
establish a plan for the custody and control of the licensee's client mental
health records in the event of the licensee's death or incapacity, or the
termination of the licensee's counseling practice. A licensee shall inform each
client of the plan." The term "incapacity" may cover a host of
circumstances: serious illness; physical injury; mental or psychological
disability, whether temporary or permanent; or substance abuse or addiction
LPC’s should not assume that these are the only circumstances that may require
transfer of client records. In order to ensure both client welfare and full
compliance with the statute and ethical guidelines, LPC’s should plan for the
safe and effective transfer of client records in case of other eventualities.
variety of other events in an LPC's professional and/or personal life can
necessitate the need to transfer patient records to another practitioner. Such
events often occur suddenly, with little or no warning, and may require
immediate action. Examples may include (but are not limited to) the following:
family or personal pressures or obligations
(e.g., the need to care for a gravely ill family member, etc.);
temporary professional change, such as a visiting faculty appointment at an
to a new city
to obtain or renew license, certification or credentials for specialized area
of practice, etc.;
discipline, including license suspension or revocation;
or other civil litigation or criminal proceedings;
of practice, either temporarily or permanently; or
the need to terminate a client's
treatment (e.g., because of personal conflicts, lack of progress, patient
with requirements for the LPC's own retention and storage of patient records,
any plan for transfer of those records should take into account certain
fundamental requirements. These plans should include a “professional will” that
specifies how the records will be transferred in case of the LPC’s death. (Holloway, J. W., 2003) Any method for transfer
should ensure that records remain legible, readily accessible, and secure.
§ 681.41(q), certain exceptions apply to the retention requirements for patient
records. LPC’s who create client records "during the scope of their
employment" by certain types of entities are not required to adhere to the
seven-year minimum for retention of records. These entities are limited to the
following three categories:
agencies at the federal, state, or local level; and
"political subdivisions or programs" of federal, state,
or local governmental agencies.
institutions" and "governmental agencies" are self-explanatory.
The label "political subdivisions or programs," however, is not so
clear. An example of a relevant "political subdivision" of a
governmental agency might be an agency task force convened to address a
particular public need. Similarly, a relevant "program" might be a
benefits or treatment program administered by, e.g., a state health or social
should keep in mind, however, that the statutory exception may not shield
counselors from liability in malpractice litigation or professional
disciplinary action. Minimal compliance with a statutory requirement may result
in loss of records necessary for defending one’s actions.
perhaps the most significant practical consideration in maintaining
confidentiality of patient records concerns the risks to electronic data.
to electronic data used to be limited largely to "hacking," or
illegally breaking into another's computer to obtain information. Hackers often
engage in such activities for "sport," rather than because they
actually want access to the information they retrieve, but the breach to client
confidentiality is no less real. With the rise in Internet usage, however,
threats to electronic data have increased drastically, and take a variety of
forms. Often, no "hacking" is required. Three of the most popular
forms are known as "viruses," "worms," and "Trojan
horses"; they refer to different types of files that are created
specifically to gain access to another's computer files to obtain data, destroy
data, or both. "Viruses" are so named because they "infect"
computer files with code that alters or destroys them. "Worms" are
named for their ability to "worm" their way into a computer's files
and wreak havoc. "Trojan horses" operate exactly as the original
Trojan horse: They appear to be innocuous files designed for ordinary use, but
they contain hidden strings of malicious programming code; once the files are
downloaded onto a computer, the code is released and disrupts or destroys the
such electronic threats can be downloaded onto a user's computer by way of a
Web browser or, most frequently, and e-mail program. In addition, while most
e-mail programs and Internet service providers offer "spam" and virus
blockers and other security measures, they are unable to keep pace with the
threats. As soon as programmers devise a way to neutralize the latest threat, a
new one is created that circumvents the latest security measures. Moreover,
many viruses, worms, and Trojan horses are designed to "mutate": They
contain program code that permits them to adapt to and avoid new security
like many other professionals, frequently belong to Internet newsgroups and
e-mail "listservs" that help them stay updated on practice
developments and other important issues. For most LPC’s, refusing to use electronic
data is impractical; under certain circumstances, it may even put them at risk
for charges of malpractice. It is thus crucial that therapists use basic
electronic security measures, such as "spam" blockers, virus
blockers, anti-virus programs, firewalls, password protection, data encryption,
and off-site back-up to ensure, as far as it is possible to do so, that patient
records remain safe, secure, and confidential. LPC’s should consider using a
separate computer for clinical records.
who protect patients' electronic records and other data as stringently as they
would safeguard their own most sensitive information are more likely to be in
compliance with state statutory and professional requirements, and are also
more likely to meet the requisite standard of care that will help them avoid
malpractice or other civil litigation.
§ 681.41, a few other general ethical requirements apply:
Subsection (v) provides that an LPC "shall not aid and abet the unlicensed
practice of professional counseling by a person required to be licensed under
the Act"; and
Subsection (w) provides that "[a] licensee or an applicant for licensure
shall not participate in any way in the falsification of applications for
these requirements, an LPC thus may not engage in unlicensed practice herself
or falsify information related to her application for licensure. However, she
also may not "aid and abet" the unlicensed practice of any student,
license applicant, or counselor under the LPC's supervision, or for whom the
LPC provides a reference. The requirement that she may not "participate in
any way in the falsification of applications for licensure" contains no
additional guidance as to the meaning of the word "participate."
LPC’s thus should assume that "participate" is defined broadly: It
likely includes not only situations in which the LPC falsifies information
herself, but situations in which the LPC knowingly permits another individual
(e.g., a student, supervisee, or applicant for whom the LPC serves as a
reference) to submit an application containing false information.
Administrative Code, Title 22, Part 30, Chapter 681:
Confidentiality and Required Reporting
(a) Communication between a licensee and client and the client's
records, however created or stored, are confidential under the provisions of
the Texas Health and Safety Code, Chapter 611 and other state or federal
statutes or rules where such statutes or rules apply to a licensee's practice.
(b) A licensee shall not disclose any communication, record, or
identity of a client except as provided in Texas Health and Safety Code,
Chapter 611 or other state or federal statutes or rules.
(c) A licensee shall comply with Texas Health and Safety Code, Chapter
611, concerning access to mental health records and confidential information.
(d) A licensee shall report information if required by any of the
(1) Texas Family Code, Chapter 2614, concerning abuse
or neglect of minors;
(2) Texas Human Resources Code, Chapter 48, concerning
abuse, neglect, or exploitation of elderly or disabled persons;
(3) Texas Health and Safety Code, Chapter 161,
Subchapter K, §161.131 et seq., concerning abuse, neglect, and illegal,
unprofessional, or unethical conduct in an in-patient mental health facility, a
chemical dependency treatment facility or a hospital providing comprehensive
medical rehabilitation services; and
(4) Texas Civil Practice and Remedies Code, §81.006,
concerning sexual exploitation by a mental health services provider.
(5) A licensee
shall comply with Occupations Code, Chapter 109, relating to the release and
exchange of information concerning the treatment of a sex offender.
End of text. You may now
take the course quiz
Psychological Association. (2003). Becoming HIPAA compliant.
Alban, A. (2007). Informed consent (part 1): its origins and
development. Retrieved on 12/7/2007
American Counseling Association. (2007). Code of Ethics. Retrieved
November 11, 2007,
The American heritage dictionary (4th ed.). Boston: Houghton Mifflin. Retrieved August 13, 2007, from
The American heritage, new dictionary of cultural literacy (3rd
ed.). 2005. Houghton Mifflin Company.
American Psychiatric Association. (2006). The principles of
medical ethics with annotations especially applicable to psychiatry. Retrieved 12/7/2007
American Psychological Association. (2007). Record Keeping
Guidelines. Retrieved 12/3/2007
Appel, J. M. (2004) May physicians date their patients’ relatives?
Medicine and Health, Rhode Island.
Bouhoutsos, J. Holroyd, J. Lerman, H. Forer, B. & Greenberg,
M. (1983). Sexual intimacy between psychotherapists and patients, Prof.
Bernstein, B. E., Hartsell, Jr., T. L. The portable lawyer for
mental health professionals: an a - z guide to protecting your clients, your
practice, and yourself , 2nd edition, Wiley, 2004, p. 22.
S. B., Jorgenson, L. M. & Sutherland, P. K. (1995 & Cum. Supp. 2000)
Sexual abuse by professionals: a legal guide. § 12-5 (c), 470-80. Charlottesville: Mitchie.
A. M. (1989). Sex between patient and therapist: Psychology's data and
response. In Gabbard, G. O. (Ed.). Sexual exploitation in professional
relationships, pp. 15-25. Washington,
DC: American Psychiatric Press,
in Therapist-patient sex as sex abuse: six scientific, professional, and
practical dilemmas in addressing victimization and rehabilitation. Kenneth S.
Campbell, M. (1989). The oath: an
investigation of the injunction prohibiting physician-patient sexual relations.
Perspectives Bio Med. In Gabbard GO (ed.), Sexual Exploitation in Professional
Relationships. American Psychiatric Press, Washington DC,
P, Gunnarsdóttir M, Hedensjö L, Andersson G, Ekselius L, Furmark T., Linköping.
(2007). Treatment of social phobia: randomised trial of internet-delivered
cognitive-behavioural therapy with telephone support. The British Journal of
Psychiatry. 190: 123-128.
Jr., O. B. (2000) Twelve pitfalls for psychotherapists. In
"Legalities," Family Therapy News. Oct./Nov. at 17.
Chaffin M; et al. 2006. Report of the APSAC Task Force on
Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems.
Child Maltreatment 11, Feb, (1): 76-89. DOI:10.1177/1077559505283699. ISSN
1552-6119, quoted in Attachment Therapy, Wikipedia. Retrieved August 13, 2007, from
http://en.wikipedia.org/wiki/Attachment_therapy#_note-Chaffin, and Desert
Morning News. (Nov. 27,
2004). Timeline: techniques blamed for several deaths. Desert
Morning News. Retrieved August
13, 2007, from http://deseretnews.com/dn/view/0,1249,595108152,00.html.
C. D., (2001). Health care scene in california.
L. (1990). Freud and Jung: years of friendship, years of loss. New York: Collier
boundaries: maintaining safety and integrity in the psychotherapeutic process. Washington DC:
American Psychiatric Press, Inc.
S. & Jones, G. (1984) Psychological impacts of sexual contact between
therapists or other health care practitioners and their clients. J. Counseling
and Clinical Psychology. 1054.
B. (personal communication, November 1984)
B. (1980, February). The therapeutic relationship: 1968, Paper presented at the
annual meeting of the California State Psychological Association, Pasadena. Retrieved 12/5/2007
F. (1989) Reminiscences of Europe, in psychoanalysis and psychosis. A. Silver,
Ed. Madison, CT: International Universities
G. O. (1995). The early history of boundary violations in psychoanalysis. 43 J.
Am. Psychoanalytic Assn. 1115-1136
& Lester. (1995). Boundaries and boundary violations in psychoanalysis.
G. O. Ed. (1989). Sexual exploitation in professional relationships. Washington, D.C.:
American Psychiatric Press.
N., et al. (1987) Reporting practices of psychiatrists who knew of sexual
misconduct by colleagues. 57 AM. J. Orthopsychiatry. 287, 293.
P. (1988). Freud: a life for our times. W.W. Norton.
A. G. (2004) Assessment of therapists' and patients' personality: relationship
to therapeutic technique and outcome in brief dynamic psychotherapy. J Pers
Hippocrates. (Transl. Adams, F.) Retrieved August 13, 2007, from
Hoge, M. A., Morris, J. A., Daniels, A. S., Stuart, G. W., Huey,
L.Y., & Adams, N. (2007). An action plan on behavioral health workforce
development. Cincinnati, Ohio: The Annapolis Coalition on the Behavioral Health
Holloway, J. W. (2003). Professional will: a responsible thing to
do. APA Monitor. Vol. 34, No. 2 Feb. Retrieved 12/3/2007
of Medicine of the National
Academies. (2006). Improving the quality of health care for mental and
substance-use conditions. Washington,
DC: National Academy
C. (1999). The Cambridge
Companion to Schopenhauer. Cambridge
University Press, pp.
145, 15, 351.
M. (2001, Jun. 19). Therapists are sentenced in
girl's 'rebirthing' death. New York Times. Retrieved August 13, 2007, from
L & Sutherland, P. K. (1993) Liability of physicians, therapists and other
health professionals for sexual misconduct with patients. In Medical liability
issues for la wyers, physicians, and insurers current trends and future
directions A-117, tort and insurance ractice section ed. Retrieved 12/6/2007
J. (2001). Boundary violations: a culture-bound syndrome. J Am Acad Psychiatry
of Minnesota Medical School,
and Head Psychiatrist, Community-University Health Care Clinic, Minneapolis
Jorgenson & Pamela Sutherland, Liability of Physicians, Therapists and
Other Health Professionals for Sexual Misconduct with Patients, in MEDICAL
LIABILITY ISSUES FOR LA WYERS, PHYSICIANS, AND INSURERS CURRENT TRENDS AND
FUTURE DIRECTIONS A-117 (Tort and Insurance Practice Section ed. 1993)
S. H., Fuller, M. & Mensh, I. N. (1973). A
survey of physicians' attitudes & practices regarding erotic and nonerotic
contact with patients. Am. J. Psychiatry 1070.
E. F., & Church, K. (2002) Psychotherapist malpractice. Kuniholm Law Firm.
Adapted from ATLA: Litigating Tort Cases, Ch. 55 "Sexual Abuse."
West and ATLA 2003.
Kupersanin, E. (2001). Lawyer offers warnings about
confidentiality pitfalls. In Legal News. 36 Psychiatric News 12. American
Leslie, R. S. Fees - the sliding fee scale. (2006) The Bulletin
Archive, Aug. Vol. 1.
Loftus, E. F. & Davis, D. 2006. Recovered memories. Annu. Rev.
Clin. Psychol. 2:469–98, doi: 10.1146/annurev.clinpsy.2.022305.095315, Annual
Lovell K, Cox D, Haddock G, Jones C, Raines D, Garvey R, Roberts
C, Hadley S. (2006). Telephone administered cognitive behaviour therapy for
treatment of obsessive compulsive disorder: randomised controlled
non-inferiority trial. BMJ. Oct 28;333(7574):883.
Lowe, P. & Ames, M. (2001, Apr. 20). Videotape, flannel cloth
convince jury. Rocky Mountain News. Retrieved August 13, 2007, from
Maddock, J. W. (1993). Ecology, ethics and responsibility in
family therapy. Family Relations, Vol. 42, No. 2 (Apr.), pp. 116-123. Retrieved
August 12, 2007,
Martinez, A. Director, Mental
Health Licensing Board, State of Colorado.
(1999). Personal communication.
J. M. (1984). The assault on truth: Freud's suppression of the seduction
theory. New York:
Farrar, Straus & Giroux.
W., Ed. (1988) The Freud/Jung Letters: The Correspondence Between Sigmund Freud
and C.G. Jung. Cambridge:
Harvard University Press.
Nicholson K. (2001, Apr. 3) Rebirthing therapy called 'torture'. Denver Post Online.
Retrieved August 13, 2007,
D. M., Gutheil, T. G., & Strasburger, L. H. (2003). This couldn't happen to
me: boundary problems and sexual misconduct in the psychotherapy relationship,
54 Psychiatric Serv. Apr. 517-22.
W. T. & Ferguson, K. E. (2003). Handbook of
professional ethics for psychologists: issues, questions, and controversies.
Sage Publications Inc, p. 185.
B. (1994). Karen Horney: a psychoanalyst's search for self understanding. (New
Haven: Yale University Press 1994)
Pierre, A. & Ravart, M. (2003).
Management of professional sexual misconduct: evaluation and recommendations, 3
J. Sex Reprod. Med. at 89.
K. S. & Vasquez, J. T. (2007). Ethics in
psychotherapy and counseling: a practical guide (3rd ed.). San Francisco: Jossey-Bass, 2007.
Pope, K. S. Developing and practicing ethics. In Prinstein, M. J.,
Patterson, M., eds. (2003). The portable mentor: expert guide to a successful
career in psychology. New York:
Springer. Retrieved 12/2/2007,
K. S. (2001). Sex between therapists and clients. In Worell, J., ed. (2001.)
Encyclopedia of women and gender: sex similarities and differences and the
impact of society on gender. Academic Press.
K. S. & Vasquez, J. T. (1998). Ethics in
psychotherapy and counseling: a practical guide (2nd Ed.). San Francisco: Jossey-Bass, 1998.
Ethical Dilemmas Encountered by Members of the American
Pope, K. S., Vetter, V. A. (1992). Ethical dilemmas encountered by
members of the American Psychological Association: a national survey. American
Psychologist. 47(3), 397-411.
K. S. (1988). How clients are harmed by sexual contact with mental health
professionals: the syndrome and its prevalence. 67 J. Counseling Dev. Dec. 222.
Pope, K. S., Tabachnick, B. G. & Keith-Spiegel, P. (1987)
Ethics of practice: The beliefs and behaviors of psychologists as therapists.
American Psychologist. Nov Vol 42(11) 993-1006. Retrieved 12/2/2007
K. S. (1986). Sexual attraction to clients: the human therapist and the
(sometimes) inhuman training system. American Psychologist, 1986, Vol 41,
pp. 147-158. Retrieved 12/1/2007
http://www.kspope.com/sexiss/research5.php , citing Durre, L. (1980). Comparing
romantic and therapeutic relationships.
K. S. (1986b). Sexual attraction to clients: the human therapist and the
(sometimes) inhuman training system. American Psychologist, 1986, Vol 41,
pp. 147-158. Retrieved 12/1/2007
http://www.kspope.com/sexiss/research5.php , citing Bouhoutsos, J., Holroyd,
J., Lerman, H., Forer, B. & Greenberg, M. (1983) Sexual intimacy between
psychotherapists and patients. 14 Prof. Psychology 185-96.
President’s New Freedom Commission on Mental Health (2003). Achieving the
promise: Transforming mental health care in America (DHHS Publication No.
SMA-03-3832). Rockville, MD: U.S. Government Printing Office.
J. I., Karterud, S., Pedersen, G, Friis, S. (2007). An empirical study of
countertransference reactions toward patients with personality disorders. Compr
G. R. (1997) Assessment & rehabilitation of psychotherapists who violate
boundaries with clients. From a paper presented to the Norwegian Psychological
Association (September 3-4, 1997) Retrieved 12/1/2007
Sharkin, B. (1995). Strains on confidentiality in college-student
psychotherapy: Entangled therapeutic relationships, incidental encounters, and
third-party inquiries, 16 Prof. Psychol., Research & Pract., 184–189.
L., Goldstein, D., Whitford, H., Thewes, B., Brummell, V., & Hicks, M.
(2006). The utility of videoconferencing to provide innovative delivery of
psychological treatment for rural cancer patients: results of a pilot study. J
Pain Symptom Manage.
C. E., Hayes, R. A. (2005). The Evidence-Based Practice: Methods, Models, and
Tools for Mental Health Professionals. John Wiley and Sons, 2005, pp. 244-245.
S, Vallin T, Waetzig EZ. (2006). Telepsychiatry improves paediatric behavioural
health care in rural communities. J Pain Symptom Manage. Nov;32(5):453-61.
S. (1988). A mind of her own: the life of Karen Horney. Jackson, TN:
The Perseus Books Group.
G. R. (1998) Sexual exploitation: a historical overview. The Walk-in Counseling
Tribune. (1995, Aug. 1). Jury awards patient $2.6
million; verdict finds therapist Humenansky liable in repressed-memory trial.
Metro Edition, accessed 8/15/07,
in http://www.stopbadtherapy.com/resource/article/diane1.shtml, and Marine, E.
C. (undated). Are you suddenly hit with a "repressed/false memory"
lawsuit? American Professional Agency. Retrieved August 15, 2007, from
Sutherland, P. (1996). Sexual abuse by therapists, physicians,
attorneys, and other professionals. World Wide Legal Information Association.
v. Regents of the University
of California. 17 (Cal.3d
Tex. Admin. Code Ann. tit. 22,
part 30, §681.41 (2004).
Texas Counseling Association.
(2007). Ethics. Retrieved November
30, 2007, from http://www.txca.org/tca/Ethics1.asp?SnID=1977744208
Texas Department of State Health Services. (2007a). Licensed
Professional Counselors & Interns by County of Practice,
9/07. Retrieved November
30, 2007, from
Department of State Health Services. (2007b). "Types of Disciplinary
Actions," Retrieved 12/1/2007.
Tex. Hum. Res. Code Ann. tit. 2 (A) § 48.
Tex. Occ. Code. Ann. §105
Tex. Occ. Code Ann. §503
v. Zezulka. 961 S.W.2d 506 (Tex.
Tjeltveit, A. C. (1999). Ethics and values in psychotherapy (1st
ed.), p. 1.
US Department of Health and Human Services. (2003). HIPAA final
privacy rules, Retrieved 11/1/2007
US Department of Health and Human Services. (1999).
Confidentiality of mental health information: ethical, legal, and policy
issues. In Mental health: a report of the surgeon general. , Chapter 7. Rockville, Md:
US Dept of Health and Human Services. Retrieved: 12/7/2007.
US Department of Health and Human Services. (2000). Protecting the
privacy of patients' health information. Retrieved 11/1/2007
Underwager, R. & Wakefield, H. (1993)Adverse psychological
evaluations in civil suits involving sexual misconduct by professionals.
American Journal of Forensic Psychology. 11 (4).
v. State, 290 N.Y.S. 2d 486 (1968).
M. H. (1992). Exploitation and Inference: Mapping the damage from
therapist-patient sexual involvement. American Psychologist. 47 (3), 412-421.
J. D. Significant cases. Retrieved 12/5/2007 http://www.johnwiner.com/significant.html.
Wolff, Ed. (1956) Contemporary Psychotherapists Examine Themselves. Springfield, IL:
Charles C Thomas.
Yourell, R. A. (2007). Personal communication.
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