Unless we are being asked to complete a trauma evaluation, our staff provide assessment and counseling services for the purpose of treatment only. In our capacity as community therapists, we will not be available to conduct a forensic evaluation or trauma evaluation for clients, offer testimony or serve as expert witnesses in a trial or hearing on behalf of clients, or provide an opinion to Child Protective Services (e.g., DCF, DSS) staff, attorneys, or the court regarding child maltreatment, custody, visitation, foster care placement, or parental capacity. Due to the vital importance of safety, confidentiality, and trust within the therapeutic relationship, if a client’s case becomes court-involved after therapy has begun and the therapist believes that this involvement has the potential to compromise the therapeutic relationship and the treatment being provided, Merrimack Valley Trauma Services reserves the right to end services and discharge the client. All clients/caregivers are required to sign a Consent to Treatment that includes this policy.
Please read the article below for more information about MVTS’ position on this subject.
“Court Involvement and The Community Therapist’s Role”
Before therapy services begin, the staff of Merrimack Valley Trauma Services (MVTS) asks the client or caregiver (if the client is a child or adolescent) to review and sign a “Consent to Services.” This document contains specific language about the MVTS therapist’s role and the nature of the therapeutic relationship, which forms the foundation of our work together. It states:
“I understand that my therapist, and other members of the Merrimack Valley Trauma Services staff, will provide assessment and counseling services for the purpose of treatment only. I understand that they do not provide forensic evaluations, trauma evaluations, nor will they be available to serve as “expert witnesses” in a trial or hearing on my behalf or my child’s behalf, in order to determine custody, visitation, foster care placement, or parental capacity.”
It is vitally important that our clients, caregivers of our clients, and all collaterals working with our clients (including attorneys, child protective workers, and court-appointed professionals) understand the role of the MVTS clinician as a community therapist and how it differs from the role of the court-involved, court-appointed, and court-ordered therapist. It is our hope that this information will lead to clearer expectations, in order to avoid miscommunication, unnecessary stress on clients and caregivers, the potential jeopardizing of the therapeutic relationship, and, in the worst case scenario, the termination of therapeutic services.
According to The Association of Family and Conciliation Courts, a community therapist is “any mental health professional providing psychotherapeutic treatment of a parent, child, couple, or family who is not involved with the legal system at any time during treatment.” When screening for the appropriateness of fit between a potential client and MVTS as the treatment provider, the clinician asks the referral source (i.e., the collateral provider, client, or client’s caregiver) the following two questions:
- Is the client being referred currently court-involved? And, if not,
- Is there is a potential for court involvement?
If the referral source answers “no” to these two questions, the intake process proceeds, as usual. If, however, the referral source answers “yes” to either of these questions, the MVTS clinician provides a detailed explanation of the differences between our role and that of a court-involved, court-appointed, and court-ordered therapist. We inform the referral source that it is our professional duty to accurately represent ourselves as trauma-focused therapists, that we will not engage in a multiple relationship with a client/caregiver (e.g., serve as their therapist, while also evaluating parenting skills or offering an “opinion” about a legal or court-related issue such as custody or visitation, etc.), as we are only able to provide services within the boundaries of our role. If the client or client’s family members become court-involved during the course of treatment, the MVTS clinician again reviews their role with the client/family in order to provide clear expectations and collaboratively determine the best course of action to prevent a negative impact on the therapeutic relationship.
What follows is a summary of four differences between the community therapist (i.e., MVTS clinician) and the court-involved therapist in the following categories: 1) the purpose of treatment, 2) confidentiality, 3) payment for services rendered, the 4) identified client with whom we are working and the nature of the therapeutic relationship. For purposes of simplification, the term “court-involved therapist” will include the roles of court-involved, court-appointed, and court-ordered therapists.
1. Purpose of Treatment
The MVTS clinician provides trauma-focused therapeutic services to the client and his/her family through psycho-education and empirically-based, clinical interventions. The goal is to assess the client’s psychological state and help meet treatment goals through therapeutic strategies, education and support, and collaboration with other providers involved with the client and his/her family, in order to improve the client’s social, emotional, behavioral, cognitive, self-concept, and developmental functioning. Improvement in functioning is determined through self-report by the client and/or reports by the client’s caregivers.
The court-involved therapist, on the other hand, provides specific therapeutic treatment to the client, which can include a parent, child, couple, or family, because the particular therapist was ordered by a judge to do so. A judge may designate a therapist to the case and a court order may be in place to describe the expected treatment. A Mental Health Forensic Expert, or forensic therapist, is a specific type of court-ordered therapist who is hired by a party or appointed by a court or a child protective agency (i.e., the Department of Children and Families or Department of Social Services) to answer a legal question through the application of psychological methods. Particular services rendered are dictated by legal questions. The court may require a sexual abuse evaluation, custody evaluation, a psychological evaluation, a competency evaluation, or another type of evaluation to assist the court in their decision-making process. A forensic evaluator is assigned to a case and his/her role is to utilize a forensically sound format to obtain uncontaminated data, entertain multiple hypotheses for the child’s symptoms and presentation, and answer the questions posed by the referral source. Information gathered is used by the court or DCF/DSS for the purpose of making decisions about custody, parenting plans, access to the child, while considering the recommendations for clinical services needed. If disputes arise regarding a court-involved therapist’s treatment, direction and clarification is sought from the court or an authorized court representative in the case.
Confidentiality can be defined as the ethical duty to a client, subject to some exceptions, to maintain that client’s privacy by not revealing information received from the client during therapy. (AFCC, 2010) Clients and caregivers are provided with a Privacy Procedures document at intake, which describes their rights and the limits of confidentiality. MVTS therapists also discuss the Mandated Reporting law and the importance of keeping children safe, along with the importance of privacy in our work with clients and caregivers. Because confidentiality and trust is vital to the success of our treatment, if we receive a request for clinical records for purposes other than treatment and/or clinical collaboration, the MVTS therapist is likely to assert the “Therapist/Client Privilege,” as per Section 507 of Massachusetts law. This law states:
“A client shall have the privilege of refusing to disclose and of preventing a witness from disclosing any communication, wherever made, between said client and a social worker [or licensed mental health clinician] relative to the diagnosis or treatment of the client’s mental or emotional condition. If a client is incompetent to exercise or waive such a privilege, a guardian shall be appointed to act on the client’s behalf under this section.”
As noted in the law, the Privilege may be waived under certain circumstances, but the MVTS therapist takes into consideration and discusses with the client/caregiver the potential for risk of harm to the client and/or the therapeutic relationship if confidentiality is broken. (See “Ways in Which Court Involvement Can Impact the Therapeutic Relationship” on page 4.)
For court-involved therapists (including forensic evaluators), the limits of confidentiality, including the individuals with whom the information about the services and the client will be shared (e.g., the court, attorneys, etc.), is clearly communicated to the client/caregiver, prior to the start of services. Depending on the extent of court involvement, the client/caregiver is informed of the goals of therapy (e.g., to determine child distress, caregiver or client functioning, treatment progress, relationship dynamics, coping skills, development, recommendations for further treatment, etc.). In the case of court-appointed trauma evaluations, it is presumed that there is no confidentiality and so the client, all caregivers, and collaterals are thusly informed.
3. Payment for Services
MVTS submits claims to the client’s insurance company for services rendered. Clients/caregivers may be responsible for a co-pay or co-insurance fee, which is determined by the client’s specific insurance plan. If a client does not have insurance or loses their insurance, MVTS offers private pay options. Payment for forensic evaluation services is made from the court or DCF/DSS directly to the evaluator.
4. The Identified Client and The Nature of the Therapeutic Relationship
In order to receive compensation for services and maintain organized records, MVTS therapists are required by insurance carriers to identify a “client.” This could be a child, an adolescent, or an adult. The therapist assigns this client a diagnosis, using acceptable standards dictated by the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. The therapist discusses this diagnosis or diagnoses with the client/caregiver. The diagnosis is also shared with the client’s insurance company during claims submission and the authorization process. When the identified client is a child or adolescent, MVTS therapists inform the client’s caregiver (including parents, foster parents, and legal guardians), both prior to the intake and during the initial meeting, that both the child/adolescent and his/her caregiver(s) are expected to fully participate in their child’s therapy. The extent to which we involve caregivers depends on various factors, including but not limited to, the client’s age, attachment factors, the client’s and caregiver’s goals of treatment, safety considerations (e.g., if one of the caregivers was a suspected perpetrator of abuse), and clinical appropriateness.
All MVTS therapists are strengths-based and empowerment-based practitioners. Consequently, our treatment model is to:
1. “Meet the client where they are at,” (i.e., work on the goals he/she chooses, not what the therapist feels is best);
2. Believe what the client tells us and assume trust in the client’s report. Since our treatment centers around the client’s perception of the traumatic events they have endured, “the facts” of the events are often not relevant in our work; and
3. Align with the client and his/her caregivers, in order to provide “unconditional positive regard,” and create a trusting relationship centered around honesty, integrity, and faith in the client’s abilities.
All of these components are vital to helping the client and caregivers heal. Due to these priorities and the fact that community therapists often serve as advocates for their clients, by judicial and legal standards, MVTS therapists could not be considered “neutral” or “unbiased.”
In contrast, the court-ordered therapist or forensic evaluator is selected by the court and there is a written stipulation of the parties. In the case of a forensic evaluator, the Court, rather than the child or caregiver, essentially becomes “the client,” as the judge dictates the focus and parameters of the services provided. Consequently, he or she is expected to adopt a neutral and objective stance.
The table below summarizes the differences between the MVTS therapist and a court-involved, forensic evaluator (Deutsch, R. and Tishelman, R., 2013).
1. The client is the child and his/her family.
2. Confidentiality belongs to the client.
3. Supportive, empathetic stance taken.
4. Confidentiality within the relationship is maintained, unless there are safety concerns, as the therapist is a mandated reporter.
5. A helping relationship: The basis of the relationship is a therapeutic alliance.
6. Information obtained mostly from the client and his/her caregivers.
7. The goal of the relationship is for the client’s benefit.
Court-Involved Forensic Evaluator
1. The client is the court/judicial system or Department of Children and Families/Department of Social Services.
2. Confidentiality is waived for the court and between clients.
3. Neutral, objective stance taken.
4. No confidentiality.
5. An evaluative relationship: The basis of the relationship is evaluation and critical judgment.
6. Information obtained from the client, his/her caregivers, and collateral resources. All information obtained is verified by multiple sources.
7. The goal of the relationship is for the court’s or DCF/DSS’s benefit.
5. Ways in which Court Involvement Can Impact the Therapeutic Relationship
When MVTS therapists are asked to become court-involved, either by their clients or by the judicial system, they must take into consideration the potential impact of the court involvement on both their relationship with the client/caregiver and the treatment they are providing. Attorneys, DCF/DSS workers, and other providers often ask MVTS therapists to step out of our role as community therapist, in order to participate in a court hearing or ask our “opinion” about matters that could potentially impact our work with clients and their families. According to the Association of Family and Conciliation Courts (2010), factors which could impact the therapeutic relationship can include, but are not limited to, the following considerations:
- Stress on the therapy, leading to conscious or unconscious distortion of information by the client, as their legal case may be affected by the release of treatment information;
- Changes to treatment focus and goals (the focus shifts from the alleviation of symptoms and improving functioning to what will be reported to the court or to DCF/DSS);
- Changes in the client’s and/or caregiver’s expectations of the therapist, especially if the therapist is asked to give an “opinion” or is told by an attorney that he/she will have decision-making authority regarding custody, parenting, visitation, and any other legal issues;
- Potential disruption of the therapeutic relationship if the caregiver feels excluded or judged by the therapist, creating an adversarial versus collaborative relationship. The relationship can further be harmed if the caregiver, who is feeling threatened by the therapist’s role, resorts to litigation, in order to obtain information; and
- If the client is a child or adolescent, fears regarding another person’s response (e.g., a caregiver) to the information being shared, as well as potential safety issues involved.
Given the complexities of trauma cases, especially those involving children, the differing roles of therapists, advocates, evaluators, and court staff in today’s healthcare environment, and the multiple demands due to the overwhelming volume of need, it is not surprising that there is confusion regarding the differing roles among therapeutic professionals. All too often community therapists will step out of their role in order to be “helpful” to other providers or out of their own need to try and “fix” helpless situations involving children. But when a community therapist provides a personal opinion about a client’s living situation, whether or not a client is “telling the truth,” parental competency, or visitation with a caregiver, he/she opens themselves up to possible ethical violations, dual relationship issues, and potential damage to the therapeutic relationship. And by offering personal opinions, community therapists perpetuate confusion among the collaterals and other providers with whom they work. The clinicians at MVTS feel that sharing appropriate and clear expectations regarding our role in a child and family’s life ensures that the therapeutic relationship is protected and that we will be able to provide the highest quality of service to our clients. We ask parents, the court, DCF/DSS, and other providers to work with us collaboratively, ask questions to clarify our services, and, above all else, respect the unique role we play as trauma specialists, as we strive to help children, families, and adults heal from the pain they have endured.
2013 Dianne P. Corbin, LISW-CP/S, CEIS
Association of Family and Conciliation Courts (AFCC) (2010). Guidelines for Court-Involved Therapy.
Deutsch, R. and Tishelman, A. (2013). Module 1: Child Maltreatment Overview. Presentation for the week of 9/3/13-9/7/13, Child Maltreatment course, Massachusetts Society of Professional Psychologists.
Kuehnle, K. (1996). Assessing Allegations of Child Sexual Abuse. Professional Resource Exchange, Sarasota, FL.
Massachusetts General Law, Section 507: Social Worker-Client Privilege. Found at www.mass.gov/courts/sjc/guide-to-evidence/507.htm.
Tishelman, A., Meyer, S., Haney, P., & McLeod, S. (2010). The clinical-forensic dichotomy in sexual abuse evaluations: Moving toward an integrative model. The Journal of Child Sexual Abuse, 19:590-608.