The AAMFT Blog

Family Therapy in Global Humanitarian Contexts

The excerpt below from Family Therapy Magazine is by Laurie Charles, co-presenter of one of the workshops chosen for AAMFT16. Interested in this topic and many others featuring the latest clinical issues in the field of marriage and family therapy? Explore the workshops and register here for AAMFT16 in Indianapolis, IN on September 15-18.

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While the content of what I deliver as a family therapy trainer in different countries is often similar, my method of delivery changes considerably from place to place. Like client families, trainee groups are really unique in their dynamics, and those unique dynamics are also totally dependent on context. As in therapy, I can plan ahead for how the training might proceed, but when I arrive in Tripoli, on the ground with 42 Arabic speaking family therapy trainees in post-conflict Libya, I have to negotiate what I planned to deliver with the unfolding dynamics of the training group I have just met and the presenting context in which they are living and working.

While family therapists may have skills that enhance the capacity to contextualize the suffering of the clients, supervisees, or trainees we work with, in global mental health one must be able to do this in relation to the broader political and economic factors in the country (Batniji, Van Ommeren, & Saraceno, 2005; Zarowsky, 2004). And it is here where family therapists need “scaling up.” Preparing U.S.-based family therapy trainees to work effectively as systemic family therapy clinicians in humanitarian relief contexts requires a shift from the nationalist focus of traditional family therapy training toward one that has a critically global lens (Platt & Laszloffy, 2010).

In training groups, I am still very conscientious about my social location (my intersectionality and identities such as gender, nationality, education and economic status, race and ethnicity, religion, ability) but must have heightened focus on how intersectionality is performed and discussed (or not) within the training group. That is because while my background may be interesting to the group for a variety of reasons, what I find is that usually I am irrelevant, because I am an outsider. What becomes more important, as in a family session, is to observe how individuals interact and perform their intersecting roles with each other, and to build on the capacity of what I see and hear. This is complex because the trainings are intense, in multiple languages besides English, and because the training group are citizens living in a highly dynamic country situation, which is often reflected in the training dynamics. My qualitative research skills of participant observation and attention to nuances of dialogue and personal expression are critical in this regard.

FTM, July Aug 2015, Vol 14, #4

407 Family Therapy in Global Humanitarian Contexts

Laurie Charlés, Catalina Perdomo. Deborah Healy, Daisy Ceja, Kathryn Dunne, Kotia Witaker

This workshop will focus on critical issues specific to the practice of family therapy within the humanitarian sphere. Presenters offer practical information and content specific to the training, supervision, and delivery of systemic family-based services where human rights and humanitarian intervention are part of the context, with a focus on making this work accessible across a variety of settings. Register

Laurie L. Charlés, PhD, has taught family therapy content, performed qualitative rapid needs assessments, and supervised and trained psychiatrists, psychosocial workers, and family therapists for programs in Kosova, Syria, Central African Republic, Cameroon, Burundi, Libya, Democratic Republic of Congo, Sri Lanka, the Philippines, Egypt, and the U.S. She is currently a Consultant with the World Health Organization, Ebola Outbreak Response, Conakry, Guinea, and is a full time assistant professor at Our Lady of the Lake University in San Antonio, TX. A former U.S. Senior Fulbright Scholar (Colombo, Sri Lanka 2010-2011), Charlés is a Clinical Fellow and Approved Supervisor of AAMFT, a Board Member of the American Family Therapy Academy (AFTA ) and chair of its Publications Committee.

Client Access to Records

Access to client records is one of those issues that prompts members of AAMFT to seek a legal/ethics consultation with AAMFT’s legal and ethics staff. When MFTs receive a request from a client to access the client record, MFTs can look to applicable laws and the AAMFT Code of Ethics for guidance.

With regard to the AAMFT Code of Ethics, MFTs can refer to Standard 2.3 for guidance. Standard 2.3 is a new addition to the Code of Ethics that came into effect in January 2015. Standard 2.3 states:

Marriage and family therapists provide clients with reasonable access to records concerning the clients. When providing couple, family, or group treatment, the therapist does not provide access to records without a written authorization from each individual competent to execute a waiver. Marriage and family therapists limit client’s access to their records only in exceptional circumstances when they are concerned, based on compelling evidence, that such access could cause serious harm to the client. The client’s request and the rationale for withholding some or all of the record should be documented in the client’s file. Marriage and family therapists take steps to protect the confidentiality of other individuals identified in client records.

You’ll notice an important aspect of Standard 2.3 that applies in the context of couple, family, or group treatment. Standard 2.3 states that in the context of couple, family, or group treatment, the therapist does not provide access to records without a written authorization from each individual competent to execute a waiver. This provision is consistent with Standard 2.2’s requirement that MFTs, in the context of couple, family, or group treatment, not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual. This provision also echoes Standard 2.2’s requirement that when providing couple, family, or group treatment, MFTs obtain the written authorization from each individual competent to execute a waiver prior to releasing information outside the treatment context. 

Standard 2.3 also discusses situations in which therapists can limit client access to records. Standard 2.3 states that MFTs limit client access to records only in exceptional circumstances when they are concerned, based on compelling evidence, that such access could cause serious harm to the client. Standard 2.3 requires MFTs to document, in the client record, the client’s request and the therapist’s rationale for withholding some or all of the record.

Client access to records is also governed by applicable laws, potentially both federal and local laws. Under many laws (e.g. US federal and state laws), there is a recognized right of access to the record. In some situations providers may be able to withhold access to some or all of the record or they may be able to provide a summary in lieu of the record. Depending on applicable laws and the facts of a given situation, the therapist’s decision to withhold access to some or all of the record may be subject to review.

For those therapists practicing in the United States, “psychotherapy notes,” as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), are a frequent topic of discussion. Generally speaking, when a client makes a request to access the treatment record, under HIPAA the therapist is permitted to exclude access to psychotherapy notes.

The section of HIPAA’s Privacy Rule that excludes psychotherapy notes can be found at 45 Code of Federal Regulations Section 164.524. It says that an individual is entitled to a copy of protected health information (essentially anything with a name or identifying number on it) except psychotherapy notes.

Psychotherapy notes are very specifically defined, but can be understood to be any recording by a therapist of the content of a therapy session. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment, the results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress (see 45 CFR 164.501). If you are thinking in terms of progress note vs. process note, psychotherapy notes are similar to process notes.

Psychotherapy notes must be separated from the rest of the record to be classified and protected as psychotherapy notes.

Generally speaking, in order to release psychotherapy notes under HIPAA, specific client authorization is required.

It is also important for therapists to understand that in the context of litigation, psychotherapy notes may be discoverable (e.g. subject to subpoena, produced by order of the court).

Some jurisdictions may have similar laws discussing psychotherapy notes or a therapist’s personal notes.

To find out what the requirements on these issues are in your jurisdiction, you can contact your licensing board or other applicable regulatory body, or a local attorney.

Release of Information or Records to Third Parties

From time to time therapists may receive requests from third parties to access the client record or requests from third parties for information about clients. These situations are often nuanced and will require thoughtful consideration of several factors. While it’s not possible to provide an answer that fits every circumstance, this post will seek to provide some big-picture concepts that would need to be considered when responding to a third-party request to access information about clients.  

In these situations, MFTs can begin by looking to the AAMFT Code of Ethics and applicable laws for guidance.

The starting point in the AAMFT Code of Ethics for these types of situations is Standard 2.2, which states:

Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law. When providing couple, family or group treatment, the therapist does not disclose information outside the treatment context without a written authorization from each individual competent to execute a waiver. In the context of couple, family or group treatment, the therapist may not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual.

Let’s begin with the opening sentence: MFTs do not disclose client confidences except by written authorization or wavier, or where mandated or permitted by law. That opening sentence should prompt MFTs to ask themselves whether the client is consenting to the release of information or whether there is an applicable law that would either mandate release or allow the provider to release information at the provider’s discretion.

To determine whether the client is consenting to the release, MFTs need to first identify who the client is—was this an individual client, couples work, family work, group work, etc. If there are multiple individuals in the client unit, MFTs can take guidance from the language in Standard 2.2 that reminds MFTs that when providing couple, family or group treatment, the therapist does not disclose information outside the treatment context without a written authorization from each individual competent to execute a waiver.

If the therapist does not have written authorization from all necessary parties to release the requested information or requested records, the therapist will be unable to release the requested information, unless the release is mandated or permitted by law. Therapists should be well-versed on exceptions to client confidentiality so that they can respond accordingly to these types of situations.

Turning specifically to requests from third parties to access the client record, sometimes therapists may be reluctant to release the record to a third party even if the client is consenting to the release. Depending on applicable laws, providing a summary may be a solution. Also, depending on applicable laws and the facts of a given case, there may be grounds for withholding access to the record. However, therapists do need to understand that confidentiality belongs to the client and the client is free to waive that confidentiality. There may be room for a conversation with the client about the risks and benefits of releasing the record, but if the client is consenting to the release and the therapist refuses to release the record in a situation where neither a summary nor withholding the record is a workable solution, the therapist may be seen as inappropriately withholding the record at some point. Exactly when that point occurs would likely depend on applicable laws and the facts in question.  

Another common question related to this topic is what records the therapist is required to provide once all necessary parties have consented to the release of the record, or it is determined that an exception to confidentiality exists (e.g. applicable law mandates or permits disclosure). The answer to this question will likely depend on applicable laws and the type of request to which the therapist is responding. In some cases, the therapist may provide only limited information, in other cases therapists may need to provide fuller access to the record.  

A quick note about permissive disclosure situations—when disclosure is permitted by applicable laws, therapists will likely need to assess the situation to determine whether they are in a situation where disclosure is appropriate given the circumstances. In other words, therapists should be prepared to identify the relevant factors that make a permissive disclosure appropriate. Consultation with peers and colleagues, as well as consultation with a local attorney and your professional liability insurer is advisable in these situations.

Stay tuned for a future post discussing client requests to access records, including a brief discussion of “Psychotherapy Notes,” as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  

As you’ll hear frequently, it is imperative that MFTs know the laws as they exist in their jurisdiction. To find out what the applicable laws are on these issues in your jurisdiction, you can contact your licensing board or other applicable regulatory body, or a local attorney.

Mental Health and First Responders: Who Will Help the Helpers?

Last month’s terrible shooting at Pulse, a gay nightclub in Orlando, shook the nation to it’s core. However, as the news of this terrifying event was breaking, there were immediate examples of heroic actions taken by the people in the club, emergency workers, police, bystanders, and locals; men and women who were at the scene of the event or who interacted with victims in the immediate aftermath who rushed in to help the victims and their families. In the days following this horrific event, in addition to the expressions of outrage, horror, and incredible sadness, there was generated an enormous outpouring of support for the victims of the shooting and their families. Social media feeds and news reports were filled with messages from people across America united in their solidarity and expressions of their desire for the families of the victims and survivors to heal from this tragedy. Due to the extremely traumatic nature of the event that occurred that terrible June night, mental health services will definitely be a component of that healing process.

When an event like this takes place, the focus is understandably on the immediate victims of the tragedy, their families and survivors and they are the ones to whom support is most readily offered as their wounds are the most obvious and cut the deepest. However, there is another group of people who are also affected, whose wounds are not as immediately evident or obvious, but who also need healing. Fred Rogers of Mr. Roger’s Neighborhood used to say, "When I was a boy and I would see scary things in the news, my mother would say to me, "Look for the helpers. You will always find people who are helping." While thankfully that is true, being exposed to a situation as frightening as events of June 12th can also be traumatizing for the helping individuals, regardless if they are a bystander on the street or someone who is on duty and trained as a first-responder.

Unfortunately, trauma suffered by the helpers in a situation is not typically as readily supported and often goes unacknowledged and untreated. Multiple studies have shown that first-responders such as Police, Firefighters, Paramedics, EMTs, nurses, and ER doctors can suffer from symptoms such as elevated stress levels, depression, anxiety, PTSD, and decline in work performance after being exposed to traumatic events in the line of duty. Elevated levels of stress and unaddressed trauma can have a deleterious effect on the mental health of someone in the helping field, particularly those in the first-responder role who may be involved at the most extreme stages of trauma. Over time, the accumulated effects of this repeated exposure can lead to distress in the person’s work and/or personal life, and can result in negative interactive patterns with co-workers, relational partners, or even children. Some studies have even shown that first-responders are at a higher risk for suicide and addictive behaviors than those who are not exposed to repeated traumatic events. Sadly, there is still a stigma against seeking mental health services and, particularly for those who have been trained to deal with extreme situations, acknowledging trauma can feel like an admission of weakness.

In the last few months the landscape that first-responders, particularly policemen and women, have found themselves in has increasingly become contentious, dangerous, and highly stressful. In the deadliest attack on our police community since 9/11, last week’s shooting in Dallas put the men and women of the first responder community there in the crossfires of a literal war zone in which the lives of five of our community service members were lost and eight more injured. The work of a first-responder has always been a dangerous one, but to be targeted and picked off like prey simply because of your uniform brings a whole new level of threat into the current environment that the first responder community faces. The feelings of vulnerability and helplessness that first responders may face when in a situation like the one that occurred in Dallas can have tremendously destructive effects on their emotional and mental well-being if not addressed and treated. That scenario in which a first responder is trying to do his or her job while enduring intense emotional and physical stress and fearing for their lives is very similar to the combat situations faced by the men and women of our military while on the front lines of war. Post-traumatic stress disorder is a very real mental health issue in our veteran community, and any severely stressful and traumatic situation can trigger PTSD in an individual regardless of their experience or how well trained they may be.

Awareness of the need for mental health services for members of our military has slowly risen over the past few years due to the increasing evidence of the detrimental effect the trauma of war can have on a person’s mental health. These findings, as well as increased advocacy efforts, have thankfully increased and improved the mental health resources available for our veterans who suffer from trauma related exposure. Now, the next step is to expand the circle of mental health care to include all those who have suffered trauma in the line of duty protecting the public, whether that be at home or abroad. The goal is to offer an avenue for any individual who has suffered “helper’s trauma” to have the support of their workplace, encouragement of the community, and the provision of a safe place to process their experiences. Through a supportive mental health network and increased awareness of the stresses that our first-responders face, we can work towards providing these services so that these men and women may return to their extremely important duty of protecting and serving the public.

One of the ways in which we as mental health service providers can begin the conversation about mental health in the first responder community is to be proactive and immersive in our approach. There are often a variety of opportunities to volunteer with the first responder community through participating in walks, runs, drives and community awareness days. These can provide some wonderful opportunities to begin to build rapport with the men and women who are the first responders in your community and their families. Often there are internal community resources in place for the first responders and their families that you can approach and offer your services to, either as a volunteer, or by asking to be listed as an additional resource for the community. You could also contact your local Police, Fire, or Paramedic agencies and organizations and offer workshops or presentations to raise awareness of the need for self-care in these fields, as well as the local resources available. Many of the members of your local first responder units may be aware of the dangers of stress and PTSD in their line of duty, and it may be a required course when going through the Police or Fire Academy, and Paramedic training, but possibly is something that has not been brought up since. They may no longer be aware of the warning signs of burnout, the tell-tale signs of trauma, or where to turn for help if they do recognize these signs in themselves or a co-worker. By becoming aware of the need for these services in our own first responder communities and offering the knowledge and support that we as mental health professionals have in this area is where we can step in to bridge the gap and begin to help the helpers.

References:
Enrich, John (November, 2014). Earlier Than Too Late: Stopping Stress and Suicide Among Emergency Personnel. http://www.emsworld.com/article/12009260/suicide-stress-and-ptsd-among-emergency-personnel

Newland, C., Barber, E., Rose, M., Young, A. (September, 2015). Survey Reveals Alarming Rates of EMS Provider Stress and Thoughts of Suicide. http://www.jems.com/articles/print/volume-40/issue-10/features/survey-reveals-alarming-rates-of-ems-provider-stress-and-thoughts-of-suicide.html

Kristal DeSantis is a Pre-Clinical Fellow, LMFT-A, wife of a first-responder, and founder of Austin STRONG: Relationship Building Center in Austin, TX

Trauma Resources

As details around this week’s tragedies in the U.S. unfold, trauma resources are available to help those needing and those providing care.

The resources below have been generated by MFTs and can help with navigating the emotionally complex areas involved with systemic injustice, trauma, racialized climates, and prevailing fear.

Resources

• Resources for MFTs in a Racialized Climate
• Tips for Parenting During Times of Crisis
• Spinning Fear
• Fear and the Family
• The Neuroscience of Fear
• Put the Oxygen Mask on Yourself First- Self Care when Working with the Traumatized 

Many MFTs in affected areas are volunteering free or low cost services to those in the community who are struggling. To find a therapist, you can utilize our directory here: Find a Therapist. In addition, these services are available:

• SAMHSA Disaster Distress Helpline
• Capitol Area Human Services in Baton Rouge
• Free mental health counseling in Minneapolis at Walk-In Counseling Center
• Low cost/sliding fee counseling services resources provided by Augsburg College Center for Wellness and Counseling in Minneapolis/St. Paul
• Trauma Support Services of North Texas providing services to crime victims
• Community counseling services through the UNT Dallas Community Counseling Clinic