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Ethical Boundary Considerations and Repressed Memories of Sexual Abuse
4 CEUs Ethical Boundary Considerations and Repressed Memories of Sexual Abuse

Section 13
Ethics: General Treatment Boundary Guidelines for Adults
Who May Have Been Abused As Children

Ethics CEU Question 13 | Ethics CEU Test | Table of Contents | Boundaries CEU Courses
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

1. Practice within the established code of ethics and practice standards
First and foremost, the mental health practitioner is advised to abide by the ethical code and standards of practice for his/her discipline. As of yet, no formal practice standards have been adopted for posttrauma treatment (in general or for postabuse and delayed/recovered memory issues). Professional organizations are only currently devising principles, recommendations, and statements as precursors to the development of standards of practice; consequently, clinicians must exercise caution and sensitivity when working with these issues.

2. Develop specialized knowledge and competence
The mental health practitioner who works with abuse-related cases has responsibility for developing specialized knowledge in issues of abuse, trauma, memory, and posttrauma treatment as well as developing competence in this treatment. In all likelihood, these issues were not addressed during the practitioner's formal clinical training since they have been largely absent from the medical and mental health curricula; therefore, they must be learned through supplemental focused training, continuing education, professional reading, and through ongoing participation in consultation, supervision, and peer study/support groups. An additional training issue pertains to students or novice therapists who, due to their apprentice status, may have neither the knowledge nor skills to work effectively with the complexities and high-risk situations inherent in many of these cases. Trainer/supervisors must closely monitor the trainee's ability to understand and manage the dynamics of these cases and, wherever possible, assign cases that are commensurate with the trainee's knowledge and developmental progression as a therapist.

3. Maintain an awareness of transference, countertransference, secondary traumatization, and self-care issues
The therapist should strive to maintain an awareness of transference, countertransference, secondary (or vicarious) traumatization, and burn-out issues that characterize these cases. Self-monitoring, self-analysis, and supervision/consultation assist in therapeutically managing rather than inappropriately reacting to or enacting patient issues. The practitioner should, whenever possible, maintain a varied caseload, avoiding one that is overly taxing and/or one comprising only abuse and trauma cases. Furthermore, the practitioner would be well advised to avoid becoming isolated in work with these patients and to engage in adequate self-care, including a variety of social outlets. It is crucial that the therapist also monitor the status of his/her mental health, seeking additional support and personal therapy during times of intense stress or crisis. When a therapist has a personal history similar to the patient's, over- or underidentification may be problematic and additional consultation may be necessary to maintain a therapeutic role and perspective.

4. Provide information about treatment and establish a therapeutic contract
The practitioner should consider using some sort of "Rights and Responsibility Statement" at the initial meeting to provide the prospective patient with information about the practitioner's therapeutic orientation and practice and the mutual rights and responsibilities of patient and therapist. Such a document is tailored to the needs and practice preferences of the individual clinician and discusses numerous issues, including assessment and diagnosis; consent to treatment, goal-setting, and treatment planning; scheduling; fees and payment; insurance issues; limits of confidentiality and reporting requirements; therapist availability and absences; cancellation and therapy termination policies; adjunctive evaluations and treatment; collateral assessments; the use of contracts for specific issues; safety issues; the use of hospitalization and medication and how determined, etc. A signed Informed Consent Statement can be used in conjunction with this general orientation statement and more specific forms prepared when any specialized technique (e.g., hypnosis, Eye Movement Desensitization and Reprocessing) is introduced and given consideration.
Preliminary information about how the practitioner works with abuse and trauma and delayed/recovered memory issues can also be included and can be supplemented with more specific materials, as needed. For example, the American Psychiatric Association Statement on Delayed Memory, a concise but comprehensive overview of these issues, can be attached to the "Rights and Responsibility Statement." This introductory material provides the basis of a mutual understanding of the practitioner's approach that is addressed in more depth and detail during the course of treatment, as discussed below.

5. Begin with a comprehensive assessment including questions about past abuse/trauma and use psychological testing and ancillary assessments as warranted
The practitioner begins treatment with a comprehensive psychosocial and personality assessment. Questions about experiencing or witnessing problematic family and childhood events (such as family violence of any sort, intra- or extrafamilial sexual contact, serious childhood medical conditions, significant family crises) should be included among other questions in the initial history-taking. These provide a baseline of information and further indicate to the potential patient the legitimacy and importance of these events and the practitioner's openness to discussing them.
At the outset of treatment, some individuals with a positive history of abuse and trauma will spontaneously disclose, others will make a direct disclosure only upon direct inquiry, others will deliberately not disclose even with direct inquiry, and others will not have such information. Nondisclosure or a "disguised presentation" of a positive history is not uncommon and may be part of the individual's posttraumatic (avoidance/ dissociative) response. For this reason, assessment should be considered as ongoing throughout the course of treatment and is reinitiated as warranted by the emergence of any new memories, issues, and symptoms. The therapist must recognize, however, that a significant number of individuals who seek therapy do not disclose because they have a negative abuse/ trauma history and thus have nothing to disclose. In this circumstance, the therapist should make no assumptions regarding the meaning of a lack of disclosure and, in particular, should not assume that the individual is consciously or unconsciously concealing an abuse history.

Psychological testing should be considered as part of the assessment. Generic screening and assessment instruments (e.g., the MMPI, MCMI, Beck Depression Scale, SCL-90) can be used to provide general assessment and diagnostic information (including comorbid conditions). In the case of known or strongly suspected abuse/trauma in the patient's background, trauma specific instruments (e.g., Dissociative Experiences Scale, Impact of Events Scale, Structured Clinical Interview for Dissociation, Traumatic Antecedents Questionnaire, Clinician-Administered PTSD Scale, the Structured Interview for Disorders of Extreme Stress, The Trauma Symptom Inventory) can provide information on trauma-related symptoms not covered systematically in the more generic instruments.

As part of the comprehensive assessment, records should be requested for any previous psychological (and, at times, medical) treatment so that issues of assessment, diagnosis, and course of treatment can be reviewed. Additionally, the practitioner should consider the utility of a second opinion, formal consultation, and ancillary assessments (e.g., psychiatric and/or medical examinations and treatment) as needed. This applies to a variety of issues but may be especially important in cases of variable/spotty or delayed/recovered memory to rule out other explanations for memory loss (e.g., organic conditions, alcoholism, or other disorders that affect memory). It is helpful for the practitioner to develop a network of professionals who are comfortable working with and consulting on the wide array of conditions and complications that typically arise in these types of cases.

6. Develop a diagnostic formulation over time and after considering a range of information
A preliminary diagnosis is made after careful consideration of the individual and his/her presenting information, symptoms, and level of functioning. Individuals who have been abused often have a variety of comorbid conditions and thus meet criteria for a number of diagnoses, including possibly Posttraumatic Stress Disorder (PTSD). Optimally, multiple diagnoses should be listed hierarchically according to their urgency and their order in the treatment process (with the understanding that treatment of one issue often--but not always---has a simultaneous effect on others and/or allows for the emergence of previously unavailable material once the original concern is successfully treated. Obviously, treatment strategies will vary according to the patient's individual diagnostic picture and general psychological condition.

When past abuse/trauma is in question, a diagnosis of PTSD is generally not made because Criterion A (i.e., witnessing, experiencing or being confronted with a traumatic event) necessary for making the diagnosis is not definitively met; however, when the symptom picture is posttraumatic without the patient's conscious knowledge of a specific trauma history, the diagnosis might be held in abeyance or given provisionally. A posttrauma and postabuse treatment model (see item 7 for a description) is adopted when PTSD is formally or provisionally diagnosed. For patients who suspect abuse yet do not have posttraumatic symptoms, a more generic treatment strategy is recommended.

7. Follow the consensus model of sequenced treatment for trauma
The practitioner is advised to establish a treatment plan that conforms with the consensus model of posttrauma treatment that is sequenced and organized initially around patient stabilization/functioning and that addresses traumatic content as necessary. The treatment is individualized and titrated according to the patient's status, needs, and available resources, is systematic rather than laissez-faire, and organized in progressive stages and tasks. The trauma is addressed according to a careful plan rather than haphazardly after the patient has developed the skills and defenses necessary to address both traumatic content and affect. Following pretherapy assessment, three stages of treatment are generally outlined in this model: (1) directed towards personal safety, stabilization, and functioning, the resolution of immediate problems and crises, the improvement of current personal and interpersonal functioning, the teaching of coping and selfsoothing skills, and the development of the therapeutic alliance; (2) addressed to the traumatic content and emotions, titrated to the individual's capacities; and (3) directed towards issues remaining after the trauma resolution stage. As noted in item 6, when no trauma history is known or determined from available information, a more generic model of treatment is advisable. This three-stage model with its initial emphasis on present-day issues and functioning resembles more generic treatment. Thus, its adoption provides for an adequate course of treatment for a patient with questions about a trauma history, whether or not such a history is later determined.
- Courtois PhD, Christine A, "Guidelines for the treatment of adults abused or possibly abused as children"; American Journal of Psychotherapy; Fall 1997, Vol. 51 Issue 4, p497

Personal Reflection Exercise #6
The preceding section contained information about treatment guideline for treating adults who may have been abused as children. Write three case study examples regarding how you might use the content of this section in your practice.

What are the three stages of treatment outlined in the consensus model of posttrauma treatment? Record the letter of the correct answer the Ethics CEU Test .

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