Facing The Challenge Of Liability In Psychotherapy: Practicing Defensively (Book Review)

Author:  Hedges, Lawrence E.
Publisher:  Northvale, NJ: Jason Aronson, 2000
Reviewed By:  Marilyn S. Jacobs, Fall 2002, pp. 43-44

Lawrence E. Hedges has written a useful book for mental health clinicians on the subject of the legal and ethical climate within which American psychotherapy is now practiced. This book, which includes a forward by Bryant Welch and a chapter on administrative law by Pamela Thatcher, received the Gradiva Award in 2001 by the National Association for the Advancement of Psychoanalysis for the best psychoanalytic book of the year. The title of this work, Facing the Challenge of Liability in Psychotherapy: Practicing Defensively, reflects the issues confronting those currently involved in mental health care delivery. There is an ever increasing risk of liability, with clinical work now more than ever subject to questioning by outside entities. The book is directed towards a psychodynamic practice orientation and thus is particularly relevant for psychoanalytic psychologists. As the title suggests, it is a primer on how a clinician can orient their work in a way that protects themselves from legal and ethical problems.

As Dr. Hedges explains in the introduction, he came to complete this project from his own evolving knowledge and role in both providing psychoanalytic treatment to patients and consultation to colleagues. His work in this area grew during the 1990’s, during which time both the increased liability involved in mental health treatment and the increased risk management-oriented professional climate coalesced to set a new standard for practice. Dr. Hedges developed an ethics course for professionals who provide long-term psychotherapy in this area. He also created a series of relevant clinical forms for clinical use. This work is an expansion of these endeavors.

Dr. Hedges articulates his purpose as related to the need to provide therapists who do long term work with a resource for their practices. This aim is in the somewhat paradoxical context of there currently being an absence of a national standard of care in this realm with there being increased scrutiny of such practice in legal and professional ethical standards!

This book is very clear, concise and logically organized. As an added benefit, the typeface is a 14-point font, making for easy readability. Included in the beginning of the work are definitions of basic terms and concepts. This addition is a helpful adjunct to those with limited understanding of the terminology of this field. It includes the actual mechanics involved in ethics complaints. Also included are issues related to standard of care in psychotherapy. These include a discussion of complex treatment issues, “therapeutic hot spots,” informed consent, diagnostic assessment, working with minors and record keeping.

Perhaps the most useful and unique aspect of this work is the fact that it is organized specifically around clinical practice and in particular, psychoanalytic clinical practice, making it a risk management primer with a strong psychoanalytic clinical sensibility. In particular, there is an emphasis upon issues that may be encountered in work with patients who have significant trauma histories. Specific concerns of our profession such as boundary dilemmas, dual relationships, and issues with recovered memories; early trauma, transference manifestations and false accusations against therapists are included as well as case material. Also included is a chapter on how to respond to complaints brought to state licensing boards. This chapter is a very comprehensive one, which also includes definitions of terms and explanations of how these entities function. I found that the summary in Chapter Ten: Practicing Defensively was most helpful in laying out guidelines for how to conceptualize our work in the current milieu.

This work also includes an Appendix of “Model Forms for Psychotherapy Practice.” These forms include informed consents for all types of purposes, including specifically psychodynamic therapy. A very thorough form entitled “Psychotherapy Client Questionnaire” is useful for initial evaluations of patients. Some of the informed consents are quite unique, such as “Informed Consent for Infant Relationship-Based Therapy,” “Informed Consent for a Visitor in a Psychotherapy Consultation,” “Informed Consent for Someone Other Than the Client to Assume Responsibility for Payment for Psychotherapy Services,” and “Informed Consent Regarding Limited Physical Contact during Psychotherapy.” These forms have the potential to be helpful to clinicians with a specific issue at hand. They also can serve as examples of how a particular circumstance that arises in one’s practice can be handled with adequate liability management. Also useful are the “Record Keeping Forms” included in the Appendix. Of particular note was the form “Organizing Experience Worksheet.” This gives an outline for the clinician of how to conceptualize a patient after the initial evaluative encounter(s). Further, forms that can be used to maintain progress note taking, periodic clinical reassessment and termination are useful templates for these tasks. Informed consents for supervision and case conferences are equally valuable. All of these forms are on an included CD, which makes for added use as a resource. The work is also valuable for the listing of attorneys (chiefly in the State of California) and a comprehensive list of references.

Dr. Hedges presents his subject with a clear sense of the realities facing clinicians at present. With regard to case material, he uses many clinical vignettes and instances of legal/ethical situations. Most of these have occurred in California and thus that state’s administrative structure is used as the real life case in point. This aspect of the book might be of limited usefulness to non-California residents. However, it is likely that the standards are quite similar (if not already evolving in the same direction) in other states.

Dr. Hedges is empathic to the struggles that clinicians now face and realistic about the vicissitudes of our work with patients. He also presents his opinions about the current challenges and how frustrating these can be to navigate. Thus, his narrative is a first person account from a seasoned therapist, which gives the work a realistic flavor.

I found this book to be a valuable addition to my library of texts related to risk management in psychoanalytic therapy. Although each of us as a provider of psychoanalytic therapeutic services would have our own interpretation of how to handle liability in our work, Dr. Hedges has given us a very helpful resource with which to problem solve.

Reviewer Note

Marilyn Jacobs is Secretary for the division and in private practice of psychoanalysis in Los Angeles.

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