Clinical Handbook V.1 April 2015 - TCCR Learning Hub
THE TAVISTOCK CENTRE FOR COUPLE RELATIONSHIPS CLINICAL HANDBOOK 2015 Version 1 (April 2015) 1 CONTENTS 1 INTRODUCTION ....................................................................................................8 1.1 TCCR STAFF: ORGANISATIONAL CHART ................................................9 1.2 TCCR CLINICAL SERVICE CHART .......................................................... 10 1.3 TCCR CLINICAL SERVICES ..................................................................... 12 1.4 TCCR KEY CONTACT DETAILS ............................................................... 14 2 REFERRAL AND BOOKING THE INITIAL CONSULTATION ............................ 17 2.1 HOW TO OFFER A CONSULTATION APPOINTMENT ............................ 17 2.2 CLIENT BOOKINGS FOR CONSULTATIONS .......................................... 17 3 INITIAL CONSULTATION AND THE ASSESSMENT PROCESS ...................... 18 3.1 BEFORE THE CONSULTATION APPOINTMENT .................................... 18 3.1.1 3.1.2 Unbooked consultations........................................................................... 18 Booked consultations ............................................................................... 18 3.2 MEETING THE COUPLE FOR THE FIRST TIME ..................................... 18 3.3 ADMINISTRATIVE TASKS DURING THE CONSULTATION .................... 19 3.3.1 Detailed account of administrative tasks .................................................. 20 (a) (b) (c) (d) (e) (f) Gather information details ......................................................................... 20 Discuss next steps.................................................................................... 20 Respond to clinical measures and outcome forms .................................... 20 If relevant, obtain permission to contact GP, referrers & other agencies ... 20 Establish preferred time and location for ongoing work ............................. 21 Negotiate the fees .................................................................................... 22 (i) The fee for the consultation ................................................................. 22 (ii) The fee for ongoing sessions .............................................................. 22 (iii) Low-fee clients .................................................................................... 23 (g) Explain policy of payment for missed appointments .................................. 23 (h) Charge for the consultation ....................................................................... 23 3.4 CLINICAL GUIDELINES FOR THE CONSULTATION PROCESS ............ 24 3.4.1 Purpose and approach............................................................................. 24 3.4.2 3.4.3 Starting the consultation meeting ............................................................. 25 Getting the information you want ............................................................. 25 3.4.4 Assessment of risk ................................................................................... 26 (a) Sources of information .............................................................................. 26 Version 1 (April 2015) 2 (i) History of risk ...................................................................................... 26 (ii) Areas of risk to look for........................................................................ 27 (iii) What to ask ......................................................................................... 27 (iv) What to do next ................................................................................... 27 3.4.5 The question of a second consultation session ........................................ 28 3.4.6 3.4.7 A note about initial consultation sessions with individuals ........................ 29 Concluding the consultation ..................................................................... 29 (a) Steps to follow .......................................................................................... 29 (b) Writing and typing the Consultation Report ............................................... 30 (c) Letter to GP, referrer and other agencies (if relevant) ............................... 31 4 ONGOING THERAPY .......................................................................................... 32 4.1 BOOKING A ROOM ................................................................................... 32 4.1.1 New room bookings ................................................................................. 32 4.1.2 Existing clinical slot: requesting a new case............................................. 32 (a) Asking for a new case via Clinician Daily Record...................................... 32 (b) Asking for a new case via email................................................................ 33 4.2 STARTING ONGOING THERAPY ............................................................. 33 4.2.1 The fee for ongoing sessions ................................................................... 33 4.2.2 4.2.3 Low-fee clients ......................................................................................... 34 Payment for missed appointments ........................................................... 34 4.3 WRITING CASE NOTES ........................................................................... 34 4.4 CLINICAL REVIEW SUMMARY (WAS ‘SIX MONTHLY SUMMARY’) ....... 35 4.5 ONGOING REVIEW OF RISK ................................................................... 35 4.6 CORRESPONDENCE ............................................................................... 35 4.7 CHANGES TO THE THERAPY STRUCTURE/FRAMEWORK .................. 35 4.8 CLINICIAN ABSENCE AND BREAKS IN THERAPY ................................. 35 4.9 DAILY CLINICAL RECORD ....................................................................... 36 5 RISK AND EMERGENCY PROCEDURES .......................................................... 37 5.1 INTIMATE PARTNER VIOLENCE: POLICY & PROCEDURES ................ 37 5.1.1 Introduction .............................................................................................. 37 5.1.2 Principles underpinning the policy ............................................................ 37 5.1.3 Intimate partner violence and abuse ........................................................ 37 5.1.4 The national context ................................................................................ 38 5.1.5 General clinical procedures ..................................................................... 38 5.1.6 More guidance on disclosure of intimate partner violence ........................ 39 Version 1 (April 2015) 3 5.1.7 Guidelines on risk assessment for intimate partner violence .................... 40 5.1.8 5.1.9 Where there are children (see also TCCR’s Child Protection Policy) ....... 41 Liaising with outside agencies and confidentiality issues ......................... 41 5.2 CHILD PROTECTION: POLICY & PROCEDURES ................................... 42 5.2.1 Introduction .............................................................................................. 42 5.2.2 Responsibilities for all clinicians ............................................................... 43 5.2.3 Identifying abuse and neglect .................................................................. 43 5.2.4 Child protection in the context of domestic violence ................................. 45 5.2.5 The risks to children living with domestic violence ................................... 45 5.2.6 The impact of domestic violence on children ............................................ 45 5.2.7 Child protection issues in pregnancy/with young children ........................ 46 5.2.8 Obstacles to recognising and acting on concerns about child protection .. 46 5.2.9 Risk assessment: picking up concerns about children ............................. 47 5.2.10 Procedures ............................................................................................ 47 5.2.11 Process of liaising or referring to outside agencies ................................ 48 5.2.12 5.2.13 When considering whether to share information, consider the following 48 Referral to Social Services ..................................................................... 49 5.2.14 Information to include in a referral .......................................................... 49 5.2.15 What would Social Services do at this point? ......................................... 50 5.2.16 5.2.17 In an emergency .................................................................................... 50 Supporting staff...................................................................................... 51 5.2.18 Implementation of the policy and training requirements ......................... 51 5.3 SAFEGUARDING VULNERABLE ADULTS: POLICY & PROCEDURES .. 51 5.3.1 Introduction .............................................................................................. 51 5.3.2 What do we mean by ‘vulnerable adult’? .................................................. 51 5.3.3 5.3.4 Defining abuse ......................................................................................... 52 Procedure ................................................................................................ 53 5.3.5 Risk assessment in safeguarding vulnerable adults ................................. 54 5.3.6 Conclusion ............................................................................................... 54 5.4 CLINICAL EMERGENCY PROCEDURES ................................................. 55 5.4.1 Warren Street and New Street ................................................................. 55 5.4.2 Pager alarm activation ............................................................................. 55 (a) Daytime up to 6pm ................................................................................... 55 (b) Evening 6pm-10pm .................................................................................. 56 5.4.3 Following an incident ............................................................................... 56 5.4.4 Risk in ongoing cases .............................................................................. 56 5.5 COMPLEX CASE LOG .............................................................................. 56 6 OUTCOME MONITORING ................................................................................... 57 Version 1 (April 2015) 4 6.1 THE MEASURES ....................................................................................... 57 (a) Measuring symptoms in the general services ........................................... 57 (i) The CORE system: Clinical Outcomes in Routine Evaluation ............. 57 (ii) The CSI: Couple Satisfaction Index ..................................................... 57 (b) Measuring experience of service .............................................................. 57 (i) Experience of Service Questionnaire .................................................. 57 (ii) End of Sessions Questionnaire ........................................................... 58 (iii) Schedules and measures .................................................................... 58 6.2 USING CLINICAL MEASURES TO MONITOR OUTCOMES .................... 59 (a) Time point: consultation appointment ....................................................... 59 (b) Time point: during regular ongoing therapy............................................... 59 (c) End of therapy forms ................................................................................ 62 7 ENDING AND FILE CLOSURE ........................................................................... 63 7.1 PLANNED ENDING: STEPS TO FOLLOW ............................................... 63 7.1.1 The penultimate session .......................................................................... 63 7.1.2 The final session ...................................................................................... 63 7.1.3 After the sessions .................................................................................... 63 7.2 UNPLANNED ENDING: STEPS TO FOLLOW .......................................... 63 8 FINANCE ............................................................................................................. 65 8.1 UNDERSTANDING TCCR’S FEE STRUCTURES .................................... 65 8.1.1 The fee for the consultation ..................................................................... 65 8.1.2 The fee for ongoing sessions ................................................................... 65 8.1.3 Low-fee clients ......................................................................................... 66 8.1.4 Payment for missed appointments ........................................................... 66 8.1.5 How clients can pay ................................................................................. 66 8.2 DEBT MANAGEMENT ............................................................................... 67 8.2.1 Ceilings for outstanding debt.................................................................... 67 8.3 ANNUAL REVISION OF FEES .................................................................. 67 8.4 INVOICING FOR SERVICES ..................................................................... 67 8.4.1 Counselling .............................................................................................. 67 8.4.2 Psychotherapy ......................................................................................... 68 9 CLINICAL FILES ................................................................................................. 69 9.1 FILE STORAGE ......................................................................................... 69 9.1.1 Active clinical files .................................................................................... 69 9.1.2 Closed clinical files .................................................................................. 69 Version 1 (April 2015) 5 9.2 TRANSFER OF CLINICAL FILES .............................................................. 69 9.3 FILE ORGANISATION ............................................................................... 69 10 CONFIDENTIALITY AND DATA SECURITY ...................................................... 71 10.1 CONFIDENTIALITY IN THE CLINICAL ENCOUNTER ............................ 71 10.1.1 Couple confidentiality versus individual confidentiality ........................... 71 10.1.2 Confidentiality of clinical documents: critical principles........................... 71 10.2 ENCRYPTED MEMORY STICKS ............................................................ 72 10.3 PROCEDURE FOR ISSUING TCCR ENCRYPTED MEMORY STICKS . 72 10.4 PROCESS NOTES .................................................................................. 73 11 EMAIL USE: POLICY AND PROCEDURES ....................................................... 74 11.1 HOW TO USE EMAIL: GOOD PRACTICE AND RISKS .......................... 74 11.1.1 11.1.2 Scope and responsibilities ..................................................................... 74 Guidance and procedures ...................................................................... 74 12 ESSENTIAL INFORMATION FOR THERAPISTS ............................................... 78 12.1 SICKNESS AND ABSENCE .................................................................... 78 12.1.1 Extended absence ................................................................................. 78 12.1.2 Holidays ................................................................................................. 78 12.1.3 Continued Professional Development and mandatory training ............... 78 12.2 TREATING ADMIN AND RECEPTION WITH RESPECT ........................ 79 12.3 DRESS CODE ......................................................................................... 79 12.4 PROFESSIONAL INSURANCE ............................................................... 80 12.5 PROFESSIONAL CLINICAL TITLES ....................................................... 80 12.5.1 Use of professional titles by clinical faculty staff ..................................... 80 12.5.2 Use of titles by non-faculty clinicians and therapists .............................. 80 12.6 INFORMATION UPDATES ...................................................................... 80 13 APPENDICES ...................................................................................................... 81 13.1 APPENDIX 1: DEPOSIT WAIVER FORM................................................ 82 13.2 APPENDIX 2: CONFIRMATION EMAIL................................................... 83 13.3 APPENDIX 3: CONSULTATION REPORT .............................................. 85 13.4 APPENDIX 4: LOW FEE FORM .............................................................. 91 Version 1 (April 2015) 6 13.5 APPENDIX 5: FINANCE INVOICE........................................................... 92 13.6 APPENDIX 6: AFTER CONSULTATION REVIEW REQUEST FORM .... 93 13.7 APPENDIX 7: CLINICAL REVIEW SUMMARY ....................................... 94 13.8 APPENDIX 8: CLINICIAN DAILY RECORD ........................................... 95 13.9 APPENDIX 9: COMPLEX CASE LOG ..................................................... 96 13.10 APPENDIX 10 CORE FORM ................................................................. 97 13.11 APPENDIX 11: COUPLE SATISFACTION INDEX ................................ 99 13.12 APPENDIX 12: EXPERIENCE OF SERVICE QUESTIONNAIRE ........ 102 13.13 APPENDIX 13: RISK IDENTIFIED FORM ........................................... 104 13.14 APPENDIX 14: RISK IDENTIFIED NOTIFICATION EMAIL ................. 105 13.15 APPENDIX 15: DISABILITY IDENTIFIED NOTIFICATION EMAIL ...... 106 13.16 APPENDIX 16: COVERING LETTER ABOUT MEASURES ................ 107 13.17 APPENDIX 17: FLY SHEET FOR OUTCOME MONITORING ............ 108 13.18 APPENDIX 18: CLOSING REPORT .................................................... 109 13.19 APPENDIX 19: ANNUAL FEE UPLIFT FORM ..................................... 113 13.20 APPENDIX 20: CLIENT INVOICE FORM ............................................ 114 13.21 APPENDIX 21: TRACER CARD .......................................................... 115 13.22 APPENDIX 22: TCCR USB MEMORY STICK DECLARATION........... 116 Version 1 (April 2015) 7 1 INTRODUCTION Welcome! We hope that this Clinical Handbook will help to orient you to our clinical services. We ask you to please read it carefully as it contains the guidelines and procedures that provide the framework for your clinical work at TCCR. The information in this guide must be read in conjunction with the TCCR Staff Handbook. Both handbooks are available in hard copy in the Common Room, Library and Reception at Warren Street and the Common Room and Reception at New Street. A digital copy of the Staff Handbook is available on TCCR’s computer network on S:\OrganisationalDrive\HR\General\Handbooks\Staff. In the digital version of the Clinical Handbook you can click on a page number in the Contents table to jump to the relevant page. These handbooks are dense with information. Don’t worry if you cannot retain it all after just one reading. As you begin to take on clients, the systems will become more familiar. Keep the handbooks as a reference. Please feel free to ask any of us for clarification on the procedures outlined here. Clinical Service Team Version 1 (April 2015) 8 1.1 TCCR Staff: Organisational Chart Version 1 (April 2015) 9 1.2 TCCR Clinical Service Chart Andrew Balfour Director of Clinical Services Limor Abramov Joint Head of Clinical Services Damian McCann Head of Clinical Service, Intake and Allocations Pierre Cachia Joint Head of Clinical Services Supervisors (Qualified) Monica LanmannJane SeymourLin ColemanSarah Fletcher John GoodchildLimor AbramovMarian O’ConnorAndrew Balfour Liz HamlinPierre Cachia Jean PennantDamian McCann Patsy Ryz Qualified Therapists Richard FlaxDorothea Longrigg Stephen GealeLin ColemanSabah Khan Perrine MoranVivian AdlerRoz AyresCaroline MedawarRuth Steedman Laura GibbonsCharlotte SimpsonElizabeth ClarksonRobert MonzoOlivia Luna Lindsey BlairHarriet DrakeYanni SpiroFelicia OlneyThomas Greally Alison ClarkeSandra YarwoodMichael MorrisPatricia Coleman Patricia Gilliland Dorota MuchaJudith JamiesonKatherine SchofieldLin TaoAngela Marks Bob LyntonSheelagh HughesPriscilla RobinsonPeta MeesStuart Tomkins Claire Watt SmyrkFrancesca JohnsonJoanna LeeMartha DoniachLuisa Kos Version 1 (April 2015) Clare ArafaFran Sinclair TaylorOrpa Daniels Sara Leon Tracey Cooke Rosemary Gaskell-TaylorNaomi GoodmanStalla VainesMadeline WoofMartha Nyman Frances EatonSarah VicaryAmita SehgalMarguerite ReidLiz Hamlin Patricia HiggsJoanna HarrisonPatricia RyzKrisztina GlausiusJuliette Andre 10 Clare Birch Limor Abramov Joint Head of Clinical Services Damian McCann Head of Clinical Service, Intake and Allocations Pierre Cachia Joint Head of Clinical Services Clinical Administration Manager Heather Williamson Senior Administrator Supervisors (PGDip, MA and MSC) Elinor Meggs Isabelle LawGolshad GhiaciChristel Buss TwachtmannJane Seymour Caroline MedawarSarah FletcherJohn GoodchildKate Thompson Peta MeesJulie HumphriesMaureen BoermaStella Vaines Mary MorganRuth ShaneViveka Nyberg Clinical Coordinator Samina Ahmad Clinical Coordinator PGDip Students Katherine AstillAmanda DormanAlison Greenig Inge FisherKam KandolaSally George Jennifer KellyJulie Githiri-GokoJoanna Kelly Etti KiaSammantha KnightElle Sidel Cara MackleyPauline OrchardJane Major Eva RembiszewskiJulie MurrayPatricia Sandford Catherine NendickDelia SchumacherJanet Newman Alice WaterfallZoe SandersAngela Jack-Earl Carole ThompsonAnna Sapounaki Version 1 (April 2015) MA Students MSC Students Deirdre Strowger Samantha Morgan Thomas Greally Cinzia Frederick Sarah Caldecott Peter Griffiths Anna Scarpellino Perrine Moran Vivian Eskin Sally Roberts Annette Tappin Dulce Merritt Sue Phillips Carole Thorpe Suzanna Mackenzie Charlotte Simpson Judith Jamieson Fatima Syedian Lisa Glynn Ruth Hazelton Matt Davies Isabelita D’Oliveria Trisha Higgs Tracy Cooke Claire Watt Smyrk Lena Fenton Olivia Luna Julie Githir 11 Sophia Ziad Clinical Coordinator Isaac Moores Administration Assistant 1.3 TCCR Clinical Services Version 1 (April 2015) 12 Version 1 (April 2015) 13 1.4 TCCR Key Contact Details Susanna Abse Chief Executive 0207 380 1957 [email protected] Nick Martin Chief Operating Officer 0207 380 1972 [email protected] Maureen Boerma Director of Training 0207 380 1971 [email protected] Andrew Balfour Director of Clinical Services 0207 380 1951 [email protected] Honor Rhodes Director of Strategic Development & Projects 0207 380 1977 [email protected] Russell Barnes-Heath Director of Finance 0207 380 1967 [email protected] Limor Abramov Head of Clinical Services (Quality and Assurance, Ongoing Therapy) 0207 380 8283 [email protected] Damian McCann Head of Clinical Services (Intake and Allocations) 0207 380 1956 [email protected] Pierre Cachia Head of Clinical Services (Clinical Projects and Business Development) 0207 380 8281 [email protected] Clare Birch Clinical Services Administration Manager 0207 380 6095 [email protected] Version 1 (April 2015) 14 Heather Williamson Senior Clinical Administrator 0207 380 1950 [email protected] Elinor Meggs Clinical Administration Coordinator (Allocations) 0207 380 8284 [email protected] Sophia Ziad Clinical Administration Coordinator (Appointments) 0207 380 1961 [email protected] Sam Ahmad Clinical Administration Coordinator (Appointments) 0207 380 1960 [email protected] Julie Humphries Programme Head PGDip 0207 380 1978 [email protected] Mary Morgan Programme Head MA 0207 380 1953 [email protected] Marian O’Connor Programme Head MSc 0207 380 1963 [email protected] Simone Matias Training Administration Manager 0207 380 1970 [email protected] Nicole Harbert Senior Training Coordinator 0207 380 1965 [email protected] Gemma Van Den Bergen Training Coordinator 0207 380 6091 [email protected] Version 1 (April 2015) 15 Conor Mackie Training Coordinator 0207 380 8282 [email protected] Edina Peto Training Coordinator 0207 380 8289 [email protected] Aizetta Bande Finance Assistant 0207 380 1968 [email protected] Dawn Pearson Finance Assistant 0207 380 6099 [email protected] Version 1 (April 2015) 16 2 REFERRAL AND BOOKING THE INITIAL CONSULTATION Clients can register and book an initial consultation appointment for our general Counselling, Psychotherapy and Psychosexual Services using our online booking system (www.bookingtccr.org.uk). This shows all available consultation appointments for the next six weeks. Alternatively, they can contact the Appointments Team and arrange an initial appointment over the phone. For specialist services such as the Divorce and Separation Consultation Service (DSCS), Parenting Together or Parents in Dispute, clients will register and book their initial consultation by contacting the relevant Clinical Services Administrator. Referrals can also be received from GPs and other professional services. For these referrals the Head of Clinical Services (Intake and Allocation) will review the referral and then the Clinical Administration Coordinator may contact the clients directly. 2.1 How to offer a consultation appointment Only clinicians who are contracted or approved by the Head of Clinical Service for Intake and Allocation should undertake consultations. Each month all TCCR’s contracted assessors will receive a form from the Appointments Team, and they should use this to specify which dates and times they would like to offer. If they cannot offer the number of consultations agreed in their contract, they should explain why this is. Students and assessors who are able to offer ad hoc consultations should contact the Appointments Team to agree dates. To spread our resources, a staff assessor and a visiting clinician or student should not offer the same consultation dates/times. The Appointments Team, under the direction of the Head of Clinical Service, will direct ad hoc assessors/students to times/days that meet client demand. The Appointments Team will put agreed consultation dates on the online system so potential clients can view consultations for the next six-week period. 2.2 Client bookings for consultations When booking a consultation appointment, clients are asked to pay a £30 deposit. This is deducted from the session fee at the end of the initial consultation meeting. The £30 deposit is non-transferable and non-refundable, so if clients cancel the session and ask to re-book for another time, they will be asked to pay a further deposit. If the client is unable to pay the deposit they can book a consultation but are asked to complete a Deposit Waiver Form (see Appendix 1). The form is sent to the clients by Appointments and, once returned, it is filed in the case file under the “Forms” section. Please note that the Deposit Waiver Form exempts the client from paying the deposit but does not waive the session fee. Once the clients have booked their consultation appointment, they will receive a confirmation email detailing the appointment date, time and venue and therapist’s name (see Appendix 2, Confirmation Email). All clients are asked to arrive 15 minutes before their initial consultation in order to complete several questionnaires: an Intake form, an Equal Opportunities Form, a Contact Details Form and two clinical measures forms (see Section 6 for further information). It is important that you familiarise yourself with these forms. Version 1 (April 2015) 17 3 INITIAL CONSULTATION AND THE ASSESSMENT PROCESS 3.1 Before the consultation appointment 3.1.1 Unbooked consultations To maximise the chance of your consultation being booked, it is ideal that unbooked consultations are available for booking on the live site until as close to the date and time of the consultation as possible. If your consultation is unbooked, the Appointments Team will agree with you when it will be removed from the system. 3.1.2 Booked consultations Once a client has booked your vacant consultation appointment, the Appointments Team will email you to notify you that your consultation vacancy has been booked. A file will be created and put in your clinical file slot at the location of the consultation. If the client has stated on the Registration Form that they have been to TCCR before, and that visit was within the past eight years, the previous case file will be placed in your slot for you to view (see Section 9.1 for further information on file storage). Before the consultation, make sure that you: a) Familiarise yourself with the questions in the Consultation Report (see Appendix 3), the Consultation Guidelines (see Section 9.3) and the instructions in this chapter. This will help you organise information as you listen, and to know what to look for. b) Collect the file from your slot, the Finance invoice and your receipt book. 3.2 Meeting the couple for the first time Just before the appointment time, ring Reception (#1999 Warren Street or #1000 at New Street) to ask if the couple have arrived. Put the phone in the consultation room on “DND” (“do not disturb”) and go down to collect them. When you arrive at Reception, and before you collect the clients, the receptionist will give you the completed intake questionnaires. Take a moment to look over the forms to identify any risk responses (see Section 3.3.1(c) below). If the clients have not managed to complete the forms, ask if they could finish them after the consultation. You will need to remind them to do so as they leave. At the beginning of the session it is good practice to thank the clients for completing the forms. Bringing the forms into the room literally, and giving clients the opportunity to talk about their experience of completing them, helps to join up the process of assessment. After the client(s) have left, you can look more fully at the forms and you may be able integrate them into your thinking before you return them to reception after the session. Never leave anyone alone in the consulting room. If someone needs the toilet, or wants water, give them directions. If one client arrives and the other is late, speak to Reception and ask the client who has arrived if they prefer to wait, rebook or start the session. If you start the session with just one client, make sure you do not turn off the phone. Ask Reception to call you once the second partner arrives, and then to direct them to the stairs. Send the partner who is already with you to meet their partner and bring them back to the consultation room. Turn off the phone. If the couple decide to rebook, explain that the deposit for today’s session is non-refundable Version 1 (April 2015) 18 and non-transferable as it represents a contribution to the cost of arranging the appointment, so they will need to pay a new deposit. When couples leave the session, it is important to encourage them to return to Reception without lingering in the corridors. 3.3 Administrative tasks during the consultation The following table gives a summary of the important tasks you need to complete in the first consultation session. Please be mindful that everything that happens in the consultation has a clinical meaning and should be viewed as part of the clinical material, not as just a matter of practical administration. That said, it is important to hold onto a pragmatic state of mind as well, to ensure that you cover the core tasks. Gather information details Verify and ensure that for both clients (if attending as a couple) we have complete personal contact details (email address, phone number, correspondence address) as well as GP details and details of any other relevant professionals. Discuss next steps Consider the type of therapy needed at TCCR, or if they should be referred elsewhere. Is an additional consultation needed to establish this? Respond to clinical measures and outcome forms Pay attention to risk items and ask about any feelings that have arisen after completing the forms. If relevant, obtain permission to contact GP, referrers and other agencies Letters to external agencies, including GPs, should be agreed by your supervisor. Establish preferred time and location for ongoing work Establish availability for days, times and locations. Stress that the waiting list is longer for peak times such as evenings – the more flexible clients can be, the more likely we are to be able to find them a suitable vacancy quickly. Negotiate the fees For the consultation and for ongoing therapy. Be clear of the range of fees we charge. Discuss with your supervisor how to explain our charging structure – have a look at the form of words used on our website if you are unsure. Be mindful of the implications for very-low-fee clients. Unless there are exceptional circumstances we would not encourage very-low-fee clients to expect an evening vacancy. Explain policy of payment for missed appointments Be able to explain TCCR’s cancellation/missed sessions policy and the rationale behind it. Charge for the consultation Complete the receipt book (3 copies), complete the finance invoice and follow the procedures for taking payment by card or in cash. Version 1 (April 2015) 19 3.3.1 Detailed account of administrative tasks (a) Gather information details It may be easier to check information details right at the beginning of the consultation. Some therapists prefer to wait till the end, but if you do this you need to feel confident about managing the timing, as you may need to interrupt clients in full flow. Check that the contact details in the file are correct. Ensure that we have an email address and a contact phone number for each client, even if they live at the same address. Check that each client has given their GP name and address on the intake forms. If they do not wish to give the GP’s name, you can explore with them why this might be straight away or discuss the issue later in the session. You may come to feel that we cannot start therapy without knowing the name of their GP. (This would be for their safety – and in most circumstances we would not write to the GP without making every effort to talk to them first. Please look at the TCCR Staff Handbook for more details.) If the couple report psychiatric involvement or Social Services involvement, try to collect information about the other professionals involved (e.g. psychiatrist/ mental health team, Social Services). (b) Discuss next steps Towards the end of the consultation, establish the type of therapy that seems to be emerging as the most suitable, and discuss this. Does TCCR appear to be an appropriate source of help, and if so in which service? Should a second consultation appointment be offered? See below for further details on these important questions. If you feel that the couple or the client might need to be referred out, discuss this with your supervisor. (c) Respond to clinical measures and outcome forms If the couple did not complete the intake questionnaires before the consultation, ask them to complete them afterwards in the waiting room. Please read through the completed forms and get a sense of how your clients are answering the questions. Are your clients feeling depressed, for example, or anxious, or suicidal? Each item has a letter associated with it. Pay particular attention to items marked “R" for risk. Once you have familiarised yourself with the forms it is easier to scan them quickly to check the answers to these risk items. When you are writing up the session, please record your impressions in brief in Section 14 of the Consultation Report. It is important that you return the couple’s completed outcome forms to reception immediately after the session. Reception will enter the data into STATA, the database we use to analyse the data. If your client scores on one or more of the risk items, Reception will send you an email to alert you of this and they will complete a Risk Form, which will be attached to the front of the completed Questionnaires. Any outcome questionnaires with a Risk Form attached are filed in the front of the case file. Once you have reviewed the forms you should file them in the section of the file marked “Forms". (d) If relevant, obtain permission to contact GP, referrers & other agencies We do not routinely contact or write to GPs or other professionals involved in clients’ care. However, there are situations in which it would be helpful for us to do so. In cases of clinical concern where there is risk (see Section 5 below), it is important to discuss with the clients Version 1 (April 2015) 20 the fact that it may be helpful for us to be in touch with other agencies and referrers such as Social Services. Such cases might include clients who have mental health issues (for example a history of breakdown or evidence of depression with suicidal ideation), and cases that involve intimate partner violence or child protection concerns. If you are unsure about this in the session, don’t worry. These issues can be discussed after the session with your supervisor and the Clinical Heads team, and together we can decide what action might need to be taken. Please see Sections 3.4.7(c), 5.1.9 & 5.2.11-14, which give further guidance on writing letters to GPs. (e) Establish preferred time and location for ongoing work You will need to establish the client’s availability for ongoing sessions – which centre can they attend, and on what days and times? Check when the Warren Street and New Street centres are open. Currently as at January 2015 both Warren Street and New Street centres operate Monday to Friday, and Warren Street also operates on Saturday morning. Be aware of the first and last session start times at each centre. TCCR OPENING TIMES Warren Street New Street Monday 08:00 - 22:00 12:00 - 22:00 Tuesday 08:00 - 22:00 08:00 - 22:00 Wednesday 08:00 - 22:00 08:00 - 22:00 Thursday 08:00 - 22:00 08:00 - 21:00 Friday 08:00 - 21:30 Closed ** Saturday 08:30 - 14:00 ** ** Opening & closing times depend on training events/clinical demand Please ensure that clients understand how important it is for them to be as flexible as possible when giving available times. Stress that the more hours they offer, the quicker they may be allocated a therapist. Ask them to let us know immediately if there is any change in their availability, or this may delay the process of allocating a regular therapist. When you record potential times be specific – rather than “lunchtime”, for instance, say “122pm”. Accuracy matters because mistakes can delay the allocation process. If clients ask how long they will have to wait to begin their therapy, you might say that it is difficult to predict and it depends how soon we can find a suitable vacancy that fits their available times. Say that we will be working hard to arrange their sessions and they will hear from us as soon as a suitable vacancy becomes available. We may contact them if there is a vacancy that does not quite match their times, in case they could manage that time after all. Let them know that they are welcome to contact us if they want to whilst they are waiting. Version 1 (April 2015) 21 (f) Negotiate the fees You will need time to discuss the fee clients should pay for both their consultation appointment and their ongoing sessions at TCCR. Most will have paid a £30 deposit to book the consultation. Remember that this amount is to be deducted from whatever total fee they are charged for the consultation. (i) The fee for the consultation This needs to reflect our clients’ ability to pay in a way that is fair to them and to the organisation; it must be set at a level that enables them to engage according to their needs in open-ended therapy. TCCR’s fees policy encourages those with means to pay a fee that subsidises those without means so they can access our services. It is important that you negotiate the rate for ongoing sessions before you discuss the fee for the consultation session. This is because our policy is to charge about twice the fee agreed for ongoing therapy – up to a maximum of £200 – for a consultation session. This takes into account the extra time and administration involved in the consultation, and the letter sent to the couple before the consultation does explain this. You can, however, negotiate a fee that is realistic for the couple to pay. (ii) The fee for ongoing sessions The email confirming a couple’s consultation appointment provides an outline of our fee guidelines for ongoing sessions. The formula we use to guide the negotiation of a weekly session fee is £2 for every £1000 of joint annual gross income – up to a maximum regular session fee of £180. If a couple are living on investments or other assets, or have particular financial pressures, you will need to make a judgement about the fee in discussion with them. Often clients have not taken in the formula, so it may make sense to start the fee negotiation by spelling out the formula above. If the couple tell you their gross annual income, you can do a quick calculation yourself to start the negotiation. If they are not happy to say how much their gross income is you should not press them to reveal this, but you can ask them roughly what level of payment the formula would place them on. Please note that the formula is just a guideline. It should only be used as a basis for beginning the process of negotiating an affordable fee. Thus for a couple who have several children and a large mortgage, and who are supporting elderly parents, you may need to adjust the calculated fee downwards. The fee should be manageable for the couple and take into account the needs of the organisation. If clients pay less than £80 per session, it is worth bearing in mind that TCCR will be subsidising the therapy. It may be useful to refer to this threshold, and to the fact that TCCR is a charity. There is a balance to strike between the couple paying an appropriate rate for a high quality service, and their realistic ability to sustain what might be a long-term therapy. If a fee is set outside the guideline figure of £2 for every £1,000 of income, give a clear rationale for this in the Consultation Report. When couples are paying a high fee this can cause anxiety for the therapist, particularly if the therapist is a student and he or she is aware that couples may be paying more than they would in private practice. It is important to understand that we are very explicitly operating a “Robin Hood” service – so those who pay a higher rate are helping the organisation to offer a service to people regardless of their capacity to pay. This commitment is to all our clients. Fees can be revisited in the course of therapy and increased or decreased should Version 1 (April 2015) 22 circumstances change. Our aim is to sustain a longer-term commitment to our clients, and our commitment is to continue to see people who need our help, whatever they can afford. Be mindful that it may be difficult for couples to discuss the fee, particularly when they are emotionally stirred up, and it is very important that you leave sufficient time for discussion. The fees discussion may, for instance, reveal an ambivalence about commitment to therapy that has not emerged earlier in the session, and you need time to think about this with the couple. Remember that fees are capped at £200 for a consultation appointment and £180 for each regular session. (iii) Low-fee clients Clients must usually pay a minimum of £50 per session for evening appointments. In exceptional circumstances we may be flexible, but it is important that therapists think carefully about this. If, for example, the clients are not working full-time and so are paying a low fee and yet are asking for an evening vacancy, this needs to be questioned before any agreement is made, as do any similar requests. If the clinician agrees a fee lower than £20 for daytime appointments, the clinician must fill in a Low Fee Form (see Appendix 4). This form asks the therapist to explain the reasons for the low fee and must be approved by a Head of Clinical Services. This procedure helps ensure that only cases that really need a low fee are taken in on that basis. Evening psychotherapy appointments are unlikely to be available unless clients are paying an ongoing session fee of at least £80. (g) Explain policy of payment for missed appointments You will need to explain TCCR’s missed session appointment policy. Explain that the couple will be allocated a specific time for regular weekly sessions, and it is unlikely that this time can be rescheduled in the course of the work. Also explain that if they have to miss a session they will be expected to pay. You can mention that the ongoing therapist may agree to see one partner if the other is away and cannot get to a session, but this will need to be discussed with the ongoing therapist. The obligation to pay for missed appointments might provoke an adverse reaction. As with other aspects of the consultation, you should try to explore what it might be stirring up for the couple – this may help later, in your formulation. It is essential that you, as an assessor, understand and sit comfortably with the idea of paying for missed appointments. Rationale: Paying for missed appointments creates a regular commitment that is important for the therapy and enables the regular therapist to establish a weekly time the couple can rely upon. TCCR expects its therapists to make a serious commitment to providing therapy on a regular basis, only cancelling for planned holidays or in the case of sickness. A matching commitment is elicited from clients, providing the basis for establishing a secure therapy. From the organisation’s point of view, it would be economically unviable for TCCR to waive the fee when clients cancel sessions. It is important to note that room itself and the couple’s time with their particular therapist are booked until the work ends, and if they cancel the session the slot cannot be given to anyone else. (h) Charge for the consultation For all cases where a deposit has been paid for the first consultation appointment, you will need to remember to deduct the £30 deposit from the total fee payable for the session. Version 1 (April 2015) 23 If the clients have booked the consultation appointment over the phone, the administrator will have attached a copy of the receipt for the deposit to the front of the file. You should give this to the client. If the clients have paid the deposit online the receipt will have been automatically emailed to them. When taking a payment for a consultation session you will need to complete both the receipt book and a Finance Invoice (see Appendix 5). All therapists are issued with their own individual receipt book and the Finance Administrator will put your invoices in your slot before a session. If the client wishes to pay by cash they should pay you in the room. For card payments please take them to the reception desk. American Express is not accepted. Please see Section 8 for further information on taking payment. 3.4 Clinical guidelines for the consultation process 3.4.1 Purpose and approach The purpose of the consultation is to give clients space to articulate their problems. It is an opportunity for us to get a picture of them and see whether we feel we can help them, and for them to think through whether this is the right path for them. You would not spell this out initially, but part of the job is to consider which of our services they may be best helped by, and whether they need to see an experienced therapist or may be seen by a therapist in training. In some cases you may decide that it would be better for the couple to be referred elsewhere. If in doubt about what would be appropriate, complete your initial consultation and detail your thinking in your report and this will be used as part of our decision making about where to place the couple. Most importantly, for most people who come into our clinical service the initial consultation is about engaging the couple or individual, and orienting them as to what is involved in entering into therapy at TCCR. If you are meeting an individual, your exploration may include considering whether they should be encouraged or helped to involve their partner in a second consultation. You may suggest that they come together to a follow-up session, or perhaps offer the other partner the option of coming in on their own before seeing the couple together. At the heart of your consultation is your experience of the kind of encounter that you have had with the couple or individual who are seeking our help. From their first contact with TCCR, clients are communicating things to us (consciously and unconsciously) about who they are and what they feel is wrong. As therapists we need to be alert to the impact they have on us from the beginning: what do they look like, how do they talk to you and to each other, how do they go about describing the problem or problems within their relationship and how do they relate to the organisation? In order to be receptive to these many communications, it is helpful to sit back for part of the consultation, letting them set the tone and shape the presentation. In time you can then comment on what you see and what you feel as a basis for beginning the work. In listening mode, one switches on a kind of internal running commentary (trying to process what they present so you can offer it back to them in an interpretive way). Incidentally this running commentary also helps you to remember afterwards. The writing of notes is discouraged precisely because we want you to be actively present and as fully receptive as possible. Everything else flows from this active availability to the dynamic encounter. What do you find yourself puzzled by? What information do you need in addition to what they are telling you, to begin to “make sense” of what they say? Have you got a glimpse of their early experience, their previous relationship experience, the story of this relationship? How can you link these Version 1 (April 2015) 24 things to what is wrong now, and also to how they are in the room with you? All these areas are dynamically relevant to the comments you begin to offer as you build a picture and start to develop a hypothesis or formulation about what is going on. 3.4.2 Starting the consultation meeting Introduce yourself and the rationale for meeting. At the outset you need to tell them that it is unlikely you will be their ongoing counsellor or therapist. You are doing only the initial consultation and they will be contacted once we have a suitable vacancy for them. Tell the clients that you have an hour and a quarter with them, but that you will need to keep 15 minutes at the end to sort out things such as the fee level and the times that they are available for sessions. Try not to get drawn into discussing this at the start, as you want to “get the feel” of the clients first so that you’ll know how to handle the discussion of fees, times, etc. It is often when you get to those topics that the couple’s ambivalence emerges and this will need to be explored if you are to complete your task. 3.4.3 Getting the information you want Everyone finds their own way to get the information needed, but a good way to start is to try, near the start, to give the couple or individual the floor for a while with an open invitation such as “Where would you like to start?”, or “What brings you here?” You may want to comment on how they proceed, who starts, how they negotiate this, whether one partner is more silent or overridden. You will need to ask the occasional question to clarify any doubts in your mind, but you are primarily trying to have an experience of them first and then fill in any gaps that strike you as important. At some point you will probably need to ask the couple about their early lives, and it is usually very informative to ask how they met and what they were first attracted to in each other. You should try some comment/interpretation of what you are beginning to think, both to give them some experience of how we work and so that you can see how they respond, and perhaps comment on that. You are seeking to understand what the presenting matter is, why this couple or individual have got into difficulties, why now, and something of what the roots of the difficulties are. What patterns are there – both in previous relationships they have had and in their early experience? You should try to make links and offer hypotheses to begin to work with them. You can talk to them about what this process has been like for them, and observe how they react. The sexual relationship between them is part of the picture we are trying to understand, and if the couple are not specific about this (either because it is not in the foreground for them or because they find this area difficult to talk about), you will probably need to ask. They may hint at “intimacy difficulties”, but it is helpful to be more specific in order to indicate to them that this is an area you are comfortable discussing. Where sexual functioning is concerned there can be medical/organic factors as well as psychological ones, and it is possible that clients are unaware of this. You may want to suggest that they seek advice from their GP. After the clients have left, it is useful to make a genogram of their close family relationships and previous relationships. As suggested before, it is essential that you familiarise yourself with all the sections in the consultation report before the session and try to obtain the relevant information. The following is a summary of pointers to look at: The appearance, manner and mode of presentation – differences between apparent and actual age, style of dress. Please note, when you write about this in your Version 1 (April 2015) 25 consultation report you must do so in a way which is respectful. The quality and experience of contact within the interview – with yourself and with each other – and any shifts that occur. Each individual’s experience of the problem – within themself or elsewhere, for instance – and where is the anxiety located? The nature of the problem/symptom at time of onset and relation to life events. The clients’ current situation. The impact on family and other relationships, e.g. children, work, education. The clients’ view of other relationships and emerging patterns. The clients view of their childhood experience, e.g. the atmosphere at home, school and social life, etc. The couple’s understanding of the history of their relationship. The clients’ capacity to take in, think about and possibly expand upon comments made by the therapist within the sessions. If you have offered a second consultation, look at their capacity to hold in mind the experience of one session until the next. Exploration with the clients of the experience of the consultation and what this might indicate in terms of treatment. The clients’ material circumstances (e.g. their living conditions) and level of functioning (e.g. their employment). 3.4.4 Assessment of risk The assessment of risk is a paramount part of the initial consultation. Please read this section carefully and be prepared to extend the consultation into an extended consultation process should you become aware of, and concerned about, risk. The information you gather may help us to protect our clients and their families and help us know what we are taking on as an agency. It will also help us decide which service would be most appropriate and whether there are actions we or the client need to take before work is undertaken here (e.g. contacting their GP, liaising with Social Services or other agencies). (a) Sources of information There is a tendency to turn a blind eye to risk. This can happen on the level of the client or clients who are not entirely aware of the risk, and also within the therapist, who might miss important information. In assessing risk you are therefore required to integrate a number of sources of information: (i) History of risk Past history of risk behaviour is the most predictive factor of future risk. Information about the suicide of close relations, previous suicide attempts by the client, self-harm, previous incidents of violence, alcohol bingeing, etc. are particularly important predictors of possible future risk. Try to be attentive to clues to matters you may need to investigate further. How do they Version 1 (April 2015) 26 appear – for instance, are they well-kept or neglected? How would you describe their manner of speech and their thought processes – are they slow, or coherent? Such areas may be pointers to depression or other difficulties such as mental illness, suicide attempts, substance abuse, violence or children at risk. Clues may lie as much in what is not said, in their behaviour towards each other or you, or in minimised aspects of their history. CORE Forms: Take a look at the responses to the “R” questions (which are about risk), because although this is not a complete source of information (the CORE relates to the past week only, so should not be relied on as the only source of information about risk). Clinicians should know what is and is not mentioned there, and check intake forms and whether GP details are complete. (ii) Areas of risk to look for Violence (see also Section 5.1). Self-harm and suicidal ideation. Alcohol and drug issues. Mental health and other problematic functioning such as being accident-prone or selfneglecting. Child protection: Always remain alert to potential safeguarding issues, especially if one of the above elements, such as domestic violence, is involved. Where are the children in this? (See also Section 5.2.) Vulnerable adults. (See also Section 5.3.) Consider the impact of “digital life” on mental health and relationship (e.g. types of porn, violent games, particular chat rooms). (iii) What to ask It is not sufficient to simply mention risky behaviour in brief on the consultation form (e.g. “He drinks”, “There was violence” etc.). Assessing risk means asking about the following (the F.O.C.S. questions): Frequency: How often does the drinking/violence/self-harm/etc happen? Onset: When did it start? How did it start? What happened at the time? (This exploration also assesses the couple’s ability to think about it rather than act on it.) Context: In what context does the risky behaviour happen? E.g. aggression after times of separation? Does drinking occur in a social context or alone (which is usually more serious)? If one of them can identify context and triggers you may wish to start thinking about a safety plan through which the risky behaviour might be avoided e.g. who can they call, and where can they go to avoid escalation. Severity: Ask what is the worst that has ever happened and assess its severity. If there was violence, for instance, were marks left? Were the police called? For drugs – what is the type of drug? What is the quantity of alcohol in one episode? What was the quantity of overdose in the case of suicidality, etc.? (iv) What to do next Whilst in the room try to explore whether the clients themselves are concerned about the Version 1 (April 2015) 27 the behaviour or thoughts you are concerned about, and if so whether they can think about what is going on. If necessary, develop safety plans – think how, for instance, the clients can keep safe. Who could they call in case things become unsafe, and what course of action could they take? Where possible we should enlist them in this thinking, and in taking action themselves rather than doing so on their behalf. Consider offering a second meeting, so you could understand things better with them. However, you may judge that clients’ level of risk either to themselves or to others necessitates that we inform their GP (or other involved professionals) – to let them those professionals know that we are involved and that we have areas of concern. The client’s permission should, wherever possible, be sought before such contact with a GP or other professional is made. Be aware of our confidentiality policy. If clients refuse permission for us to contact relevant professionals, try to explore this but be aware that we may not be able to offer therapy if clients do refuse their permission to contact professionals who work, or have worked, with them. In high risk cases you may consider with a Head/Director of Clinical Services whether to call the GP or another agency after the session. In very rare and serious cases we may need to liaise whether or not clients give their permission. However, this would only happen where there is imminent risk to a child or an adult’s safety, and only after discussion with a Head or the Director of Clinical Services. Please record all details and concerns in the file within 24 hours of seeing the client or clients. Always discuss your concerns with your supervisor and/or a Head of Clinical Services. 3.4.5 The question of a second consultation session If you do feel that you need to see the clients for a second consultation (for example if there is clear ambivalence about coming for therapy or there are risk factors which need a further consultation session) please say that you would like to see them again and that we will contact them in the next day or two with another appointment. After the first consultation appointment you will need to contact the Appointments Team to book a time on the diary when the second consultation can take place. You should then draft the text of the email to be sent to the clients offering the second appointment (see email policy for guidelines on drafting emails). You will need to make sure that you include a date by which the clients must respond to accept the offered appointment. Make notes for yourself on this first session and write up the report as usual, indicating in your report that you decided to see them for a second time. This initial report should go into the file in case there is some delay before the second appointment and the file is needed in the interim. You cannot fill out the final part of the form, relating to the “outcome” of the consultation, until you have seen them again. If you feel that they might need a second consultation but are unsure about this, say to them that you would like to think further about today’s meeting and will get back to them in the next couple of days with your thoughts about how best to proceed. After the second meeting, write your account of the second session on a separate piece of A4 paper (making it clear on the first report that there is a second document detailing the second session). You also need to update the end of the main consultation report with details of the outcome of the whole consultation. Having written a separate report for each of the meetings, please make it clear on each of the reports that there are two reports. Sometimes you may find that it is not until after the session that you are alerted to just how Version 1 (April 2015) 28 severe the clients or patients difficulties are. This may influence your decision to see them a second time – in this circumstance you should email or phone the client saying something like “On reflection, following our recent meeting, I think it would be useful for us to meet a second time to get things a bit clearer before proceeding.” Also, please do not forget that you can always say you need to see the couple or individual a second time if you feel it would be useful to discuss your concerns with someone before you see them again. It may be that after discussion the best outcome for the couple or individual would be for us to refer them out (see Section 3.4.7). Bear in mind that unless an individual or couple can pay at least £60 we are unlikely to find a private vacancy for them. When you have completed the consultation if you wish to request the file to be reviewed, there is a specific request or difficulty, please complete the After Consultation Review Request Form (see Appendix 6). 3.4.6 A note about initial consultation sessions with individuals If only one client comes to the consultation this may be because the client has no partner. On some occasions only one partner may attend because the couple did not understand the importance of both coming or because only one is prepared to come or indeed one partner wants to talk alone first. You may be able to help the attending client to involve the other for a second consultation appointment. This would be necessary if both are to be involved in any ongoing work. We do need to see them together before ongoing couple work can be offered. Please note that when the other partner attends for a consultation, reception will need to be alerted that the client needs to complete the intake forms. In addition, if only one partner attended the first session and the couple are both coming for the second consultation, please allow time for a discussion about confidentiality and say that usually we assume that information can be shared between them. If it is clear that only one partner is going to be involved then we need to think about why they would wish to continue with us rather than being referred for individual therapy. The following guidelines should help with this exploration. We would normally refer the individual to another agency for individual therapy if, for instance: they have never had a couple relationship the presentation is chronic and severe or suggests mental health difficulties We would usually work with an individual client when the difficulties seem to be located in a current or in recent relationships. This should be discussed in supervision as it can be a difficult distinction to make and is rarely a clear cut one. Please make a note of this thinking in your report. 3.4.7 Concluding the consultation (a) Steps to follow The following is a summary of the steps to follow after the initial consultation. Version 1 (April 2015) 29 i. Discuss the outcome of the consultation with your supervisor. If risk is presented, discuss the case with either a supervisor, consultation workshop lead or a Head of Clinical Services in order to make a final decision about the outcome of the consultation. ii. Type the Consultation Report (See section 10 on ensuring the confidential report complies with confidentiality requirements). The report should be added to the file and placed in the designated tray for Admin within seven days of the consultation. iii. If relevant, write to the GP or other professionals involved. See Section 3.4.7(c) on guidance for writing to professionals. Discuss any such letter with your supervisor. iv. If referring out: Follow the guidelines below on how to make a referral to another agency/practitioner. (b) Writing and typing the Consultation Report The consultation report must be typed and printed. Please present the information gathered in a clear, coherent way. It is important to give your view about the couple under each of the headings. Please write succinctly (we are not looking for a novel), making sure to fill in section 17 and 18 on the outcome of the consultation at the end of the report. (See the section above on writing up second consultation appointments.) The completed report should be handed in within 7 days of the final consultation session. No full names, contact information or other identifiable personal data should be included on the report. This information should be added by hand when you are at TCCR and handing in the file. Documents should only be saved on TCCR’s encrypted memory stick and under no circumstances should consultation and other clinical reports be saved on personal devices. All documents containing clinical information must be password protected (see Section 10.1.2 for further guidelines about this). When writing the report please be mindful that occasionally clients do ask to see their file, and such requests must be referred to a Head of Clinical Service. Please be mindful to write in a professional, reflective, caring way, and to avoid offering harsh judgements or offensive, physical descriptions of the clients. If for any reason the report cannot be handed in within the deadline please email the Clinical Services Administration Manager, copying in the Head of Clinical Services (Intake and Allocation) and let them know when the report will be handed in and why you were unable to comply with the deadline. When you have completed the consultation if you wish to ask for the case to be reviewed, because there is a specific request or difficulty, please complete the After Consultation Review Request Form (see Appendix 6) and place this in the clear pocket on the front of the file. This will trigger an alert to one of the Clinical Service Heads to review the file. Version 1 (April 2015) 30 (c) Letter to GP, referrer and other agencies (if relevant) We do not write routinely to GP and referrers. However, in case of risk, such as high violence potential, major depression, suicidality, child protection and other concerning situations, it is important to discuss with the clients that it would be helpful to involve other agencies. Following consent to this and always following a discussion with a supervisor or Head of Clinical Services, a letter should be written to the GP or other relevant agency or professional. GP letters should be brief (no more than one page of A4) and should not normally contain any unnecessary personal information. They should indicate your concerns and any recommendation to the GP. Clients may ask to have a copy of this letter. Letters to other agencies/professionals should also be brief and to the point. Letters to GPs should be in letter format and should include: The client name, current address and date of birth. The date of the original referral. The date of the first session. The number of times the client has been seen to date. A brief outline of the main presenting problem and the clients’ current state. General professional opinion of the problems. The types of treatment offered. Your view of the degree of any risk the patient may pose to themselves or others. A recommendation of action for the GP, e.g. to monitor, provide information, refer to a psychiatric assessment etc, if applicable. Referral of clients out of TCCR to other agency/therapist: Complete the Consultation Report as above and discuss with your supervisor or Head of Clinical Services (Intake and Allocation). We may feel it is appropriate to give the couple or individual information so that they can make other contacts themselves, e.g. with an individual therapist or counselling organisations etc. This can be done in low risk cases. Referral out can be felt as a rejection and should be handled with sensitivity, and you should discuss this with your supervisor and inform a Clinical Head that a referral out has been made. Version 1 (April 2015) 31 4 ONGOING THERAPY 4.1 Booking a room Before you can be allocated a case you need to have a clinical vacancy. This means you need to have room reserved on the diary. 4.1.1 New room bookings You can book a new slot by emailing the Appointments Team ([email protected]) who will check if a room is available on the diary. So they can do this quickly, please provide the following information: Day, date and time you need the room. If it is a one-off booking, what date do you wish to book the room for? If it is a new slot for regular sessions, what is the start date? What type of clinical session are you booking? A consultation, co-therapy or regular threesome session? When booking a room, the following rules apply: All client appointments start on the hour or the half hour. All threesome appointments (counselling, psychotherapy and psychosexual) last 50 minutes. All foursome co-therapy slots last 60 minutes (with an additional 15 minutes for therapists to discuss the session after the clients leave). First consultation appointments last 75 minutes. Please note that until a case is allocated into a slot, vacant slots may be used for one-off room bookings by other therapists. If you are booking a room as a new slot in which to hold regular sessions, the Appointments Team will notify the Allocations Team that you want a new case and the vacancy will be added to the Vacancy Boards. Students must receive their supervisor’s permission to take a new case. 4.1.2 Existing clinical slot: requesting a new case If you are looking for a new case for an existing slot, you need to inform the Allocations Team that you want a new case for your vacant slot. You can do this via the Clinician Daily Record or by emailing [email protected]. Please update the Allocations Team if your start date for taking a new case changes. (a) Asking for a new case via Clinician Daily Record You can request a new case in one of the following ways: i. Via Today’s Appointments section (top): if your case is about to end, complete the section to the right of the case that is ending. Record the date of the last session of the current case, and the date you can take a new case. ii. Via Empty Slots section (bottom): if you case has already ended, your vacant slot will be listed in the Empty Slots section. To the right of the vacant slot details record the date you can start a new case. Version 1 (April 2015) 32 (b) Asking for a new case via email You can email the Clinical Administration Coordinator for Allocations that you are ready for a new case at [email protected]. Once a new case has been allocated to you, the Allocations Team will email you to confirm that the allocation has been made and give you the date of the first session and the case number. The case file will be put in your slot at the centre where you will see the new case. If your supervision sessions are at a different centre, a copy of the Consultation Report will be put in your slot at that location, so you can discuss the case in supervision before the therapy begins. 4.2 Starting ongoing therapy It is usual to start the first session by introducing yourself and by asking the couple generally where they would like to start. If GP or contact details are missing from the file, this first treatment session should be used to address these issues. The first ongoing sessions are in effect a form of extended consultation. They can be used to explore more deeply the questions raised in the initial consultation. Areas of importance include the assessment of risk, history, etc. The end of the first session is an opportunity to clarify the framework of the therapy, for example meeting every week, how the payment system works (see Section 8 on our payment systems), the need to pay for missed appointments and the fact that sessions cancelled by the therapist are not charged. Clients’ queries in these areas should be explored, and it is important that clinicians fully understand the reasons behind these parameters. See below for the rationale behind our fee payment. If you have any queries, please speak with your supervisor. 4.2.1 The fee for ongoing sessions The formula we use to guide the negotiation of a weekly session fee is £2 for every £1000 of joint annual gross income – up to a maximum of £180 for a regular session, and the email confirming a couple’s consultation appointment provides an outline of our fee guidelines for ongoing sessions. See Section 3.3.1(f) for details about how the clinician who did the initial consultation will have worked with the clients to judge their ongoing fee. The fee should be manageable for the couple and take into account the needs of the organisation. If clients are paying less than £80 per session, it is worth bearing in mind that TCCR will be subsidising the therapy. If clients express concern about this during ongoing work, it may be useful to refer to this fact, and to the fact that TCCR is a charity. There is a balance to strike between the couple paying an appropriate rate for a high quality service, and their realistic ability to sustain what might be a long-term therapy. When couples are paying a high fee this can cause anxiety for the therapist, particularly if the therapist is a student and he or she is aware that couples may be paying more than they would in private practice. It is important to understand that this is because we are very explicitly operating a “Robin Hood” service – whereby those paying at a higher rate are helping the organisation to offer a service to people regardless of their capacity to pay. This commitment is to all our clients. Fees can be revisited in the course of therapy and increased or decreased should circumstances change. Our aim is to sustain a longer-term commitment to our clients, and our commitment is to continue to see people who need our help, whatever they can afford. Version 1 (April 2015) 33 Discussion about fees may reveal an ambivalence about commitment to therapy, and you may find it helpful to think about this with the couple. 4.2.2 Low-fee clients Clients in the counselling service must usually pay a minimum of £50 per session for evening appointments. In exceptional circumstances we may be flexible about this. Evening psychotherapy appointments are unlikely to be available unless clients are paying an ongoing session fee of at least £80. If the clinician at any stage agrees a fee lower than £20 for daytime appointments, the clinician must fill in a Low Fee Form (see Appendix 4). This form asks the therapist to explain the reasons for the low fee and must be approved by a Head of Clinical Services. 4.2.3 Payment for missed appointments Be aware of TCCR’s missed session appointment policy, which will probably have been discussed in the consultation appointment. You can remind clients that it is unlikely that their current allocated time can be rescheduled in the course of the work, and that if they have to miss a session they will be expected to pay. The consultation clinician may have mentioned that the ongoing therapist might agree to see one partner if the other is away and cannot get to a session. You can discuss this with your supervisor. The obligation to pay for missed appointments might provoke an adverse reaction. As with other aspects of the consultation, you should try to explore what it might be stirring up for the couple – this may help with your formulation. It is essential that you understand and sit comfortably with the idea of paying for missed appointments. Rationale: Paying for missed appointments creates a regular commitment that is important for the therapy and enables the regular therapist to establish a weekly time the couple can rely upon. TCCR expects its therapists to make a serious commitment to providing therapy on a regular basis, only cancelling for planned holidays or in the case of sickness. A matching commitment is elicited from clients, providing the basis for establishing a secure therapy. From the organisation’s point of view, it would be economically unviable for TCCR to waive the fee when clients cancel sessions. It is important to note that room itself and the couple’s time with their particular therapist are booked until the work ends, and if they cancel the session the slot cannot be given to anyone else. 4.3 Writing case notes You need to complete the case notes in clients’ files as soon as possible after each appointment so that the record is up to date. Record the date of each scheduled session and whether the clients attended. If they did not attend, record this fact and the reason why the session was cancelled. If it was you who cancelled the session, mention this and record when the sessions are due to resume. In the Summary section you need to: Describe the main themes of the session. Make sure that what you write is legible and coherent. If there is an increased risk, indicate this clearly and describe any action taken in response. Note in later sessions if the risk decreases. Version 1 (April 2015) 34 4.4 Clinical Review Summary (was ‘Six Monthly Summary’) Cases in ongoing treatment should have the Clinical Review Summary (see Appendix 7) completed twice a year, in July and December, and also before any break in therapy. The existence of a Clinical Review Summary means that – in case of emergency or if your couple get in contact when you are away – senior clinicians can quickly see what the key themes of the work have been. It is also helpful to have an overview of the therapy process if the couple come back to therapy at TCCR at a later stage. Writing the Clinical Review Summary is an opportunity to look back at the last weeks or months in therapy, and to summarise the main themes that have emerged. Reading through the file and session notes is a helpful process in its own right, one that can provide unexpected insight about the couple. Please mention on the form any risk and point to any relevant information that would be useful for the senior therapist. Please complete the form for every case you have been seeing for ongoing therapy sessions, including those who came for just a few sessions. You should complete the summary in July and December even if you are not taking a break then. The Clinical Administration Manager will email you a reminder before each time point, attaching a copy of the form. The form must be typed and must comply with our confidentiality policies (see Section 10). 4.5 Ongoing review of risk Every contact with clients involves a review of risk, and this needs to be recorded in the case notes along with any evolving risk concerns and actions taken. Please refer to Section 3.3.1(c) and (d) and Section 5 on risk for guidance. If you have any concerns about risk please discuss these with your supervisor. 4.6 Correspondence An administrator will file copies of all emails sent or received via the Clinical Administration Team in the “Letters and Correspondence” section of the client file. A note of all professional discussions about the case and all phone calls made by the therapist to the clients or other professionals should be recorded and filed in the “Case Record Summary” section of the file. 4.7 Changes to the therapy structure/framework Therapists are reminded that they are working in an organisational context and any changes in the therapy framework (e.g. a fee discount, a change to the frequency of sessions or debt accumulation) must be agreed with the supervisor before any such changes are agreed with the client. If the change discussed in supervision is outside TCCR’s usual practice, the supervisor must discuss this with a Head of Clinical Service. 4.8 Clinician absence and breaks in therapy If the clinician knows they will be away for a long time, or will have a break in therapy beyond a normal holiday break, a Head of Clinical Service must be consulted. Before such a break a Clinical Review Summary (“six monthly”) should be typed and placed in the file. The therapist needs to document in the case notes any discussions about how the couple would like to proceed, and whether they know about alternative resources while the Version 1 (April 2015) 35 therapist is away. The file should be given to the Appointments Team, who will update our system. See Section 12.1 for further information on sickness procedures. 4.9 Daily clinical record You will be given a Clinician Daily Record (see Appendix 8) which you must complete for each working day. The document is very important as it tells the clinical administrators: That the case has ended and when exactly you want a new case to start (see Section 4.1.2 for further information), or That the case has ended and you no longer need the slot, or If the case is continuing, when the next session will take place. Your completed record should be submitted by posting it into the green box in the admin office (Warren Street) or handing it to the receptionist (New Street only). Version 1 (April 2015) 36 5 RISK AND EMERGENCY PROCEDURES This chapter introduces TCCR’s policy on potential risk in three main areas: Intimate partner violence Safeguarding vulnerable adults Child protection Each issue is dealt with in a self-contained section that provides you with guidelines for good practice. Liaising with your supervisor, and possibly with other senior clinicians, is of particular importance when it comes to managing risk. 5.1 Intimate partner violence: policy & procedures 5.1.1 Introduction It is likely that, among couples who come to TCCR, some have been or are currently involved in domestic violence and abuse. (In 2005, Relate estimated that 30% of those with whom they worked were affected by domestic violence). Here we describe the principles underpinning TCCR’s policy on intimate partner violence and Abuse and provide guidelines for use when violence is reported in the clinical setting. 5.1.2 Principles underpinning the policy Couple relationships are key to the health and wellbeing of the nation. Where couple relationships are poor, children and adults suffer. TCCR has a commitment to social concern and to diversity in every area. At the heart of TCCR’s ethos is the belief in the importance of the therapeutic relationship and its ability to enhance and heal the lives of adults and children. TCCR aims to improve the quality of adult couple relationships, prevent family breakdown and support positive parenting, and thereby to promote healthy development in children. TCCR has a central belief in the importance of understanding the dynamic aspects of a couple’s difficulty. 5.1.3 Intimate partner violence and abuse Definitions of intimate partner violence and abuse draw particular attention to issues of power and control, and to patterns of abuse within the couple relationship that reflect attempts by one partner to systematically intimidate and abuse the other. Research indicates that this is usually, though not exclusively, male violence directed at women. That said, however, much of the violence encountered at TCCR involves the eruption of abusive behaviour between partners in a couple in response to a variety of stresses, threats of abandonment or overwhelming intrusions. When considering domestic violence and abuse, it is also crucial to recognise that such abuse takes a variety of forms, i.e. physical, sexual, emotional and financial abuse, destruction of property, spiritual abuse, stalking, harassment, etc., and that often these forms of violence and abuse occur simultaneously. It can include violence from teenage or grownVersion 1 (April 2015) 37 up children to parents, and violence between siblings. In addition, it can include the abuse of older people or other vulnerable adults, such as people with dementia living with their partners. 5.1.4 The national context The safeguarding of both adults and children forms a primary focus in working with couples where there is violence and abuse, especially since such abuse can result in serious injury, rape and/or death. In addition, violence and abuse will often be witnessed by children and the adverse effects of this must be recognised as a child protection issue. The Adoption and Children Act 2002 recognises domestic violence and abuse as a source of “significant harm” for children. Living with domestic violence and abuse affects children’s physical, emotional and psychological wellbeing and is often linked to poor outcomes in education, antisocial behaviour, substance misuse and serious mental health issues. It is also acknowledged that coercive controlling violence and abuse can manifest itself through the actions of immediate and extended family members, i.e. through the perpetration of illegal activities such as forced marriage, honour crimes and female mutilation. Moreover, extended family members may condone or even share in the pattern of abuse. Lesbian, gay, bisexual and transgender people may be especially vulnerable, and issues such shame, stigma, mistrust of authority (particularly the police), fear of having children taken away because of incorrect stereotyping, “outing” etc can lead to the abuse/violence being hidden and unreported. There are also issues around safe havens for transgender people and their children, and some women’s refuges may not accept men who have not fully transitioned. In 2005 the UK government, in line with the United Nations and World Health Organisation, launched a national delivery plan to tackle and reduce domestic violence and abuse. In addition to initiatives involving the criminal justice system, this plan also requires agencies such as our own, who have contact with individuals or with couples experiencing domestic violence and abuse, to facilitate safe disclosure by their clients and to offer interventions in ways that are both appropriate and effective. In the clinical situation, this places a particular responsibility on the practitioner to closely examine the nature of the couple dynamics and to formulate a treatment approach based on the understanding of the couple relationship. 5.1.5 General clinical procedures During an initial consultation or in ongoing work clients may disclose actual violence or abusive practices in their relationship. The therapist might also hear descriptions of events or circumstances which suggest that violence or abuse is taking place, or might be. In all situations where the therapist has concerns about violence and abuse, it is imperative that these are actively and carefully explored with the couple in order to decide whether it is possible to take them into the service or to continue with their therapy. This is a judgement that will need to be reached in discussion with the supervisor and the Director of Clinical Services or a Head of Clinical Services. It will be based on an assessment of risk. Depending on the level of risk it will sometimes be necessary to offer to see each partner separately for one or two sessions, in order to explore the nature and extent of the abuse and to determine the level of fear and clarify issues of safety. It may then be possible to meet with the couple to discuss the options and, if the decision is to go ahead with therapy at TCCR, to consider with them how best to proceed with this. Please see guidelines on Version 1 (April 2015) 38 risk in Section 5 below. When an allegation of physical harm or sexual or emotional abuse is made by one partner about another, at any point, whether in the consulation process or in the course of ongoing work, therapists must always take it seriously. The situation needs to be explored carefully with the couple and the therapist must document their concerns and discuss them with the supervisor in the first instance. Even if there is no overt reference to violence, where the couple or individual refer to conflict taking place it is important that the therapist ask directly about how bad the arguments get – to ascertain whether and to what extent they escalate into physical or emotional violence or abuse. This is important both in order to assess the situation and to signal to the couple/individual that this can be thought about and discussed. It is important that the supervisor discuss concerns reported by the therapist with the Head or Director of Counselling and Psychotherapy at an early stage, or with whoever is deputising for him or her. The therapist should make a detailed record of the session in which the concern arose, differentiating between fact, reported information and opinion. After this discussion, a decision will need to be made about managing the case and supporting the therapist. The most likely case management decisions to be made at this point are whether to stop or proceed with therapy, whether to make an alternative referral and whether to liaise with appropriate external agencies (see below). 5.1.6 More guidance on disclosure of intimate partner violence Enquire about the episode(s) of violence. How severe has the violence been? The therapist should always be clear with clients that all incidents need to be taken seriously and any disclosure, or concern about violence, needs to be explored. If the therapist feels that to do so in the session would make the situation less safe, or more volatile, then this must be discussed immediately after the session with the supervisor or the Head or Director of Clinical Services. The next step may be a meeting/discussion with the partners separately. Assess whether the violence has been habitual and pervasive or has arisen in relation to a particular situation such as threats of abandonment or life stresses. How bad has it been, at its worst? (Having an idea of the worst incident is an important guide to how it might possibly be in the future, if things become stirred up for the couple.) Ask for an example. Try to form a picture of what happened, what led up to the incident and what each partner was feeling. Get an idea of the ABCs of the violent episodes (that is, what are the Antecedents, what is each partner’s Behaviour and what are the Consequences of the episode?). Think with the couple how to minimise or reduce triggers, and to plan for safety. If an incident of violence has occurred or seems likely to occur, it is important to address very directly with the couple, or the individual, a plan for establishing safety. How far is each partner able to think about the violence? Is there a feeling of concern about what happens, or simply blame? Is there any evidence that responsibility can be taken for what happens? Do you feel that the partners minimise the significance of what they are telling you? Version 1 (April 2015) 39 What about children? To what extent can the couple think about the impact of violent incidents upon the children? (See below.) During the consultation, notice needs to be taken of whether there are other complicating factors, such as the use by one or both of drugs or alcohol. If there are such factors, information about contact with statutory and specialist organisations should be gathered. If it is apparent that either partner has used drugs or alcohol before attending a therapy session, the session should not continue and the therapist should terminate it as soon as possible. If the work with the couple is to proceed, both partners should show evidence of wanting help in order to end the violence, and the same is true if working with an individual. If therapy at the TCCR is assessed as suitable, risk and safety will continue to be monitored as part of the ongoing work, in discussion with the supervisor. In discussion with the supervisor and consultation with a Head of Clinical Services or the Director of Clinical Services, a decision needs to be taken as to whether liaison with other agencies/GP is indicated, and whether the couple or individual are considered suitable for therapy at TCCR. (An important aspect of this decision may be: if they are suitable, under what conditions? For instance, does there need to be consultation or liaison with their GP, with Social Services or with another agency alongside any work offered here?) See Sections 3.4.7(c) and 5.1.9 below for procedures for liaising with outside agencies and issues of confidentiality. The outcome of assessment and subsequent discussion needs to be carefully documented and passed on to a Head of Clinical Services or the Director of Clinical Services. The Clinical Administration Manager must also be informed of the case number, as a centralised list of cases where domestic violence has occurred is kept. 5.1.7 Guidelines on risk assessment for intimate partner violence Assessing risk involves assessing the probability that a harmful behaviour or event will occur. This requires determining the frequency of that behaviour or event, its likely impact and who it will affect. Please be aware that in some situations providing this information may pose a risk to one or either partner. If providing this information seems to elicit fear in one or both partners, it may be necessary to see them separately for this part of the work. If the couple or individual talk about violence as a problem in their relationship or they are aware of an escalation in their arguments that suggests the threat of violence, it is important to assess whether the violence has a habitual and pervasive nature. Essentially you are looking for signs of coercive and controlling behaviour from one partner to another, as this would indicate that couples therapy might not be safe or appropriate. Either way, the therapist needs to make a clear record of this in the file and discuss with their supervisor. If it is disclosed that there is a court injunction in place or there are ongoing legal proceedings related to domestic violence/abuse, it is unlikely that it would be appropriate for TCCR to offer couple work, at least until the outcome of the legal proceedings is clear. Again, this would need to be discussed in supervision and with a Head of Clinical Services and the Director of Clinical Services. Unattended-to current alcohol or substance misuse may be a contraindication to Version 1 (April 2015) 40 psychotherapeutic work being able to take place, and referral to the appropriate agency will probably have to be made. This must be discussed in supervision and with a Head of Clinical Services or the Director of Clinical Services. In discussion with the supervisor it may become clear that an extended consultation with the couple, either together or separately, should be offered in order to see if TCCR is the appropriate organisation to help the couple/individual. With the support of their supervisors, therapists are assessing whether it is safe to work with the couple or whether there is a likelihood of the therapy provoking further violence and abuse. Please be aware that the more contexts in which the individual or couple have shown violence or abuse, the more the risk increases. It is important to check that the GP details are on the Registration Form; if not, they should be obtained. This links to the issues of confidentiality and liaison with other services (see Section 5.1.9 below). 5.1.8 Where there are children (see also TCCR’s Child Protection Policy) The therapist should make an initial assessment to determine the impact upon the child or children of witnessing domestic violence between a couple. This needs to explore: The level of risk to the child or children. The level of care provided. The couple’s account of the child’s emotional health. The couple’s account of the child’s physical health. Their description of the child’s development. The extent of each adult’s ability to protect the child. It is important that the supervisor should at an early stage discuss the situation and the concerns reported about the impact on any children with the Director of Counselling and Psychotherapy or whoever is deputising for him/her. At all times detailed records of sessions need to be kept. Following discussions a decision will need to be made as to whether local child protection guidelines should be followed (see Child Protection Policy below). 5.1.9 Liaising with outside agencies and confidentiality issues Please be aware of the following procedures relating to liaising with outside agencies and dealing with confidentiality issues arising from this. Confidentiality: TCCR’s policy is that we will not disclose information about clients to a third party except in situations where there is a serious and significant concern about harm to them or to someone else. In this instance, we would (except in exceptional circumstances, see below) ask for their permission to contact other professionals, such as the GP or a social worker. All therapists must be clear about TCCR policy on the limits of confidentiality. Liaison: If there are concerns about significant harm, or about an individual’s mental health, or if there are other agencies already involved in the case, there may be a need to liaise with other agencies or services. Such situations must be discussed by the therapist with their supervisor or another senior clinician. Version 1 (April 2015) 41 If, following such discussion, there is believed to be a need to liaise with outside agencies, such action must always be discussed with the supervisor and/or a Head of Clinical Services or the Director of Clinical Services. The need to liaise with an outside agency, such as the clients’ GP or Social Services, should be discussed with the couple or individual and their co-operation sought. Except in exceptional circumstances (see below), this process of discussing, and of obtaining the clients’ permission for contact to be made, should always be followed. As a general point, letters to professionals outside TCCR, such as the client’s GP, need to contain the minimum information necessary to protect client safety and to alert the GP/other professional to the fact that their patient is in treatment and may, for example, become distressed in the therapeutic work. This establishes a link with the GP, should further liaison become necessary during the work, and allows the GP to know about the therapeutic work in order to inform their response should their patient consult them for help with emotional problems. All such letters must be discussed with the supervisor of the case, or a Head of Clinical Services or the Director of Clinical Services. When clients do not consent to TCCR contacting outside agencies, we may nevertheless do so if the concerns are judged to be sufficiently serious and significant. The law does not prevent the sharing of information with other agencies in the absence of consent, where failure to do so would result in a child (see below) or others suffering serious neglect, or physical, sexual or emotional abuse, or where disclosure is required under a Court Order or other legal obligation. In this situation, only relevant details and information should be shared and therapists should limit information to that which is necessary. The therapist should consider: Is there a legitimate reason for sharing the information? Has consent from the couple/individual been sought? If consent to share information is refused, is there serious and significant risk that failure to do so would place someone at risk of significant harm? How much information needs to be shared? If the step is to be taken of referring to outside agencies without consent, have the couple/individual been informed that this is happening? Where appropriate, the therapist should endeavour to maintain a therapeutic contact with the clients. In some circumstances, referral to outside agencies without consent may be made without informing the couple/individual. However, this must only happen in exceptional circumstances where it is judged that discussion with the individual/couple would place a child or someone else at significantly greater risk. Such an action must be discussed with a Head of Clinical Services or the Director of Clinical Services before it is taken. 5.2 Child protection: policy & procedures 5.2.1 Introduction This policy outlines the processes to be followed in the event of child protection concerns arising in the work of therapists at TCCR with couples and individuals. These processes Version 1 (April 2015) 42 adhere to the law as defined by the Children Act 1989 and are informed by the policy and procedures of the Tavistock and Portman NHS Trust (Lawlor, 2010), as well as the London Child Protection Procedures 2007 and the policy document Safeguarding Children Abused through Domestic Violence (London Safeguarding Children Board, 2008). TCCR clinicians working with adult couples have a responsibility for safeguarding children. In the course of their work, they may become aware of a child suffering, or likely to suffer, significant harm. Allegations of physical harm, sexual or emotional abuse and neglect may be made by one parent about another in the context of the clinical encounter. Although there is the possibility that a conflictual relationship context may provoke unfounded allegations (especially with separating and divorcing parents in dispute over contact, residence and financial matters), such allegations must always be taken seriously. TCCR therapists need to be aware of the risk of neglect, emotional abuse and domestic abuse to children of the couples/individuals they are working with. Therapists should be able to consider the needs of any child in the family of their clients and consider referral to other services for support for the family as necessary and appropriate. Where there are concerns about children, liaison with other agencies and services becomes crucial and may include the GP, Social Services, a Health Visitor and others. This may require sharing information to safeguard the welfare of children or to protect a child from significant harm. The following procedures are a guide to how to proceed in this difficult area, and must be followed. 5.2.2 Responsibilities for all clinicians Clinicians working at TCCR should be competent in the following areas. They: Must be familiar with TCCR clinical policies on child protection. Must be aware of how to obtain help and advice in relation to child protection matters. Must follow the TCCR Child Protection Policy when there are child protection concerns. Must understand that personal information about children and couples cannot be disclosed without consent. However, the law permits the disclosure of confidential information necessary to safeguard the interests of the child – protection of a child or children overrides the right to confidentiality. Should consult with senior colleagues in all cases where there are concerns about child protection, and follow the procedures detailed below. 5.2.3 Identifying abuse and neglect Abuse and neglect are forms of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family, or in an institutional or community setting, by those known to them or, more rarely, by a stranger (for example via the internet). They may be abused by an adult or adults, or by another child or children. Physical abuse: this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child. Emotional abuse: this is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate or valued only insofar as they meet the needs of another person. It may include not giving Version 1 (April 2015) 43 the child opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age-inappropriate or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and limitation of exploration and learning or preventing the child participating in normal social interaction. It may involve seeing or hearing the illtreatment of another. It may involve serious bullying (including cyber bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone. Sexual abuse: this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways or grooming a child in preparation for abuse (including via the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children. Neglect: this is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to provide adequate food, clothing and shelter (including exclusion from home or abandonment), to protect a child from physical and emotional harm or danger, to ensure adequate supervision (including the use of inadequate caregivers) or to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional need (Working Together to Safeguard Children, 2010) Significant Harm: There are no absolute criteria on which to rely when judging what constitutes Significant Harm. Consideration of the severity of ill-treatment may include the degree and the extent of physical harm, the duration and frequency of abuse and neglect, the extent of premeditation, and the presence or degree of threat, coercion, sadism and bizarre or unusual elements. Each of these elements has been associated with more severe effects on the child, and/or relatively greater difficulty in helping the child overcome the adverse impact of the maltreatment. Sometimes a single traumatic event may constitute significant harm, for example a violent assault, suffocation or poisoning. More often, significant harm is a compilation of significant events, both acute and long-standing, which interrupt, change or damage the child’s physical and psychological development. Some children live in family and social circumstances where their health and development are neglected. For them, it is the corrosiveness of long-term emotional, physical or sexual abuse that causes impairment to the extent of constituting significant harm. Under Section 31(9) of the Children Act 1989 as amended by the Adoption and Children Act 2002: “Harm” means ill-treatment or the impairment of health or development, including, for example, impairment suffered from seeing or hearing the ill-treatment of another. “Development” means physical, intellectual, emotional, social or behaviour development. “Health” means physical or mental health. “Ill-treatment” includes sexual abuse and forms of ill-treatment which are not physical. Under Section 31(10) of the Act: Where the question of whether harm suffered by a child is significant Version 1 (April 2015) 44 turns on the child’s health and development, his or her health or development shall be compared with that which could reasonably be expected of a similar child. To understand and identify Significant Harm, it is necessary to consider: the nature of harm, in terms of maltreatment or failure to provide adequate care; the impact on the child’s health and development; the child’s development within the context of their family and wider environment; any special needs, such as a medical condition, communication impairment or disability, that may affect the child’s development and care within the family; the capacity of parents to meet adequately the child’s needs; and the wider and environmental family context. Of course, TCCR therapists are not making judgements based upon seeing the child themselves, and so cannot be definitive, but they are making a judgement based upon the accounts of the parents and from the experience of working with the parents in the clinical setting – and the decision is whether it is necessary to refer on to other agencies, particularly Social Services, in order to assess the child and family, or to seek other forms of help from children’s services such as CAMHS. Please see below for guidance in making this judgement. 5.2.4 Child protection in the context of domestic violence Children who witness domestic violence suffer emotional and psychological maltreatment. They tend to have low self-esteem and experience increased levels of anxiety, depression, anger and fear, aggressive and violent behaviours, including bullying, lack of conflictresolution skills, lack of empathy for others and poor peer relationships, poor school performance, anti-social behaviour, pregnancy, alcohol and substance misuse, self blame, hopelessness, shame and apathy, post traumatic stress disorder – with symptoms such as hyper-vigilance, nightmares and intrusive thoughts – images of violence, insomnia, enuresis and overprotectiveness of their mother and/or siblings. A study by Bowker, Arbitell and McFerron (1988) found that the more frequent the violence between the partners, the more extreme the physical abuse of the children. The authors concluded that “the severity of the wife beating is predictive of the severity of the child abuse”. 5.2.5 The risks to children living with domestic violence These include: Direct physical or sexual abuse of the child. Research shows this happens in up to 60% of cases; also that the severity of the violence is predictive of the severity of abuse to the children. Emotional abuse and physical injury to the child from witnessing the abuse. 5.2.6 The impact of domestic violence on children This is similar to the effects of any other abuse or trauma and will depend upon such factors as: The severity and nature of the violence. The length of time the child is exposed to the violence. Characteristics of the child’s gender, ethnic origin, age, disability, socio-economic and cultural background. The warmth and support the child receives in their relationship with others such as siblings and other family members. Version 1 (April 2015) 45 The nature and length of the child’s wider relationships and social neworks. The child’s capacity for and actual level of self-protection. 5.2.7 Child protection issues in pregnancy/with young children Thirty per cent of domestic violence begins or escalates during pregnancy, and it has been identified as a prime cause of miscarriage or still birth, premature birth, foetal psychological damage from the effect of abuse on the mother’s hormone levels, foetal physical injury and foetal death. The mother may be prevented from seeking or receiving proper ante-natal or post-natal care. If the mother is being abused this may affect her attachment to her child. Babies under 12 months old are particularly vulnerable to violence. Where there is domestic violence in families with a child under 12 months old (including an unborn child), even if the child was not present, any single incident of domestic violence must be taken particularly seriously, and must trigger the child protection processes outlined below. Professionals should make a referral to local authority children’s social care, in line with Section 5.2.11 – for further information see London Child Protection Procedures (London Board, 2007). If there are children under the age of seven in the family, this could raise the level of risk as young children are more vulnerable because they do not have the ability to implement safety strategies and are dependent on their parents to protect them. In cases such as this, the characteristics of the child and situation which are “protective” need to be carefully considered. Violence between the parents may draw attention away from the fact that a child in the family may be being sexually or physically abused or targeted in some other way (e.g. the child could be the focus of paranoid thoughts). (London Safeguarding Children Board, 2008) 5.2.8 Obstacles to recognising and acting on concerns about child protection There can be many feelings/anxieties that can lead to abuse being missed, or the seriousness of the concerns about child protection issues failing to be registered and responded to appropriately by the clinician. These might include: The fear of losing the treatment alliance with the couple in therapy. The discomfort of disbelieving or being found to have wrongly suspected clients. Anxieties about breaching confidentiality. A focus on understanding the internal reasons why maltreatment may have occurred, particularly when there is no perceived intention to harm the child. Uncertainty about how to judge the situation, and how to take up the concerns with the parent or couple and what to write in the clinical file. Losing control of the therapy as a consequence of referring to other agencies such as Social Services, and doubts about the benefits of this. Anxiety that, in the short-term at least, it may make the situation worse and cause trauma for the couple/family. Personal safety of the therapist if they feel threatened by the clients. Fear of complaints or litigation from clients. Anxieties about seeking support from colleagues or discussing clinical work with senior staff. Version 1 (April 2015) 46 Anxiety or uncertainty about liaising with other professionals such as social workers/GP etc. Difficulty of judging how to respond, and whether the presentation really indicates significant harm that needs to be acted upon. The following guidelines outline the steps to follow in making this judgement. 5.2.9 Risk assessment: picking up concerns about children Child protection issues may be part of the background to the case, associated with the initial referral – for example, where the couple are referred by the courts or Social Services because of concerns from the outset about parenting. In such cases there will need to be careful assessment in order to determine the suitability of the referral and the parameters around the liaison with Social Services and other agencies negotiated at the outset. It is vital that we have knowledge of, and contact details for, other agencies/professionals involved in the care. There must be discussion with referrers and with our clients about the contact/liaison that TCCR clinical staff will need to be able to have in order to work with the couple in therapy. There may also need to be discussion with other agencies, such as Social Services, to establish the parameters around the work – for instance it may be necessary to talk about the need to balance confidentiality (so the couple can be worked with therapeutically) with the need to liaise and ensure that other agencies are aware whether the couple are engaged in the work and of significant concerns that arise during the work. These issues should be part of the intake process and are the responsibility of a Head of Clinical Services and others, such as the Head of the Parenting Together Service, and ultimately of the Director of Clinical Services. When child protection issues arise for the first time during the initial consultation or treatment, the therapist’s assessment should explore: The level of risk to children. The level of care provided. The couple’s account of the child’s emotional health. The couple’s account of the child’s physical health. Their description of the child’s development. The extent of each adult’s ability to protect and think about the child’s wellbeing and safety. The following steps are a guide for clinicians in responding to child protection concerns that emerge at any point in their contact with their clients. 5.2.10 Procedures a) Discuss your concerns as quickly as possible with your supervisor. If your supervisor is unavailable and you cannot speak to them quickly, then contact a Head of Clinical Services or the Director of Clinical Services. b) During holiday periods or at other times when a Head of Clinical Services or the Director of Clinical Services may be unavailable, TCCR will nominate a senior therapist to provide clinical cover and will disseminate the name(s) of these people to all therapists. c) Document in detail the session in which concerns arose. Do this immediately, if Version 1 (April 2015) 47 possible, and certainly within 24 hours of the session in which the concerns arose. Be clear to distinguish between fact, reported information and the therapist’s opinion. d) All subsequent discussions and decisions regarding the case must be clearly noted in the file, and each entry must be dated. e) If the case is first discussed with the supervisor, and the concerns about child protection persist, the next step is discussion with a Head of Clinical Services and/or the Director of Clinical Services, who must be alerted immediately to the need to discuss the concerns. f) An internal planning/discussion meeting with a Head of Clinical Services or the Director of Clinical Services must then take place. The Director (or, in their absence, a Head of Clinical Services) is responsible for convening this meeting and for preparing a report detailing the issues, and the decisions taken. g) If the concerns are felt to be serious then liaison with other professionals/agencies is the next step. Questions to address at this stage: i. Are there other professionals already actively involved in the case with whom the concerns should be discussed in the first instance – e.g. GP, Child and Family Mental Health Services, Social Services? ii. If there are no other agencies/professionals already involved, then a decision must be taken about liaison and referral to outside agencies/professionals. Most particularly, whether to refer the case to Social Services. 5.2.11 Process of liaising or referring to outside agencies Concerns are discussed with the couple/individual and their cooperation with a referral to Social Services is sought. Unless there are very strong grounds for not doing so (see below), the clients should be informed of the need to refer the family. The therapist should endeavour to help them stay in therapy during this process, if this is appropriate. a) Where the couple/individual do not agree/give their consent to TCCR contacting Social Services, contact will nevertheless be made if the concerns are judged serious. The law does not prevent the sharing of information with other practitioners in the absence of consent, if the public interest in safeguarding the child’s welfare overrides the need to keep the information confidential. b) Professionals have a duty to disclose information: i. Where failure to do so would result in a child or others suffering from neglect, physical, sexual or emotional abuse, or ii. Where disclosure is required under a court order or other legal obligation. 5.2.12 When considering whether to share information, consider the following Is there a legitimate reason for sharing the information? Has consent from the couple/individual been sought? If consent to share information is refused, do the circumstances meet the “public interest test” – that is, are there serious concerns that failure to do so would result in a child or others suffering neglect or emotional and physical abuse? Has this judgement been reached after following TCCR policy (above)? Version 1 (April 2015) 48 In the event of referring to Social Services without consent, the couple/individual should be informed that the referral is being made and, where appropriate, the therapist should endeavour to maintain a therapeutic contact with the clients. Informing Social Services or other agencies of our concern about the welfare of children without informing the parents and discussing it with them should only happen in exceptional circumstances, and only after discussion of the situation with a Head of Clinical Services or the Director of Clinical Services, or a senior clinician deputising for them. This situation might occur, for example, where there is a fear that discussion with the individual/couple would place the child or children at greater risk, or if the couple/individual have left us with grave concerns and are out of contact with our agency and not responding to our attempts to speak to them. Where there is uncertainty about whether to make a referral to Social Services, the local Child Protection Coordinator or Child Protection Officer can be contacted for a discussion of the case – and this is usually possible without needing to mention names or to make a formal referral first. They will advise on whether they consider a referral is necessary. However, this must be discussed with your supervisor and with a Head of Clinical Services, before taking any action. 5.2.13 Referral to Social Services Informing Social Services should be undertaken by either a Head of Clinical Services or the Director of Clinical Services, or another clinician in a senior, clinical position at TCCR, but only after following the processes detailed above. Where the case is already known to Social Services, the social worker allocated to the case or their line manager should be spoken to. Where the case is not known to Social Services, the referral will need to be made to the Referral and Assessment Duty Social Worker or Manager. If we do not already have them, the Clinical Administration Manager will assist in obtaining the contact telephone numbers of the relevant Social Services department for the case, where possible. Telephone referrals to Social Services will usually require a faxed confirmation on the same day, where possible, to a named individual. An acknowledgement should be received by telephone within one working day. If Social Services have not confirmed receipt of the referral within two working days, this should be followed up by a Head of Clinical Services or the Director of Clinical Services. 5.2.14 Information to include in a referral The following information would normally be included in a referral: Full names, dates of birth of the parents and number and gender of the children. Address of the family and GP details. Salient events in the family history. Cause for concern. Other agencies or professionals involved now or in the past, e.g. psychiatrist. Version 1 (April 2015) 49 Some detail of the involvement with TCCR: How long have they been seen? Are we continuing to work with them? Have they been able to use the work? Have they consented to the referral to Social Services? 5.2.15 What would Social Services do at this point? Social Services are likely to take the following action in response to our contact with them. Consult with other agencies that have direct knowledge of the child and family. Plan the investigation/assessments to be undertaken. If they decide there are no child protection concerns, record their decision not to proceed and consider any actions that they may feel would nevertheless be required to safeguard the child’s or children’s welfare. Alternatively, decide to commence a child protection investigation, under Section 47 of the Children Act 1989. Issue an invitation to Child Protection Conferences (meetings of professionals involved to discuss the case) if it is possible that there may be further requests for input – e.g. from the TCCR therapist involved or for court reports. (Any such requests must be discussed with the therapist’s supervisor and a Head of Clinical Services or the Director of Clinical Services. Whilst the position is that TCCR therapists should contribute as necessary to such processes, the nature of that contribution needs to be carefully considered and the therapeutic relationship with clients needs to be thought about. The Heads of Clinical Services and the Director of Clinical Services are responsible for discussing such requests with Social Services or other agencies and for deciding an appropriate course of action with them that takes into account the implications of any action on the therapeutic process if the couple are continuing in therapy at TCCR, alongside the primary need to ensure that the child is protected.) 5.2.16 In an emergency TCCR is not an emergency service and it is unlikely, given the nature of our work, that child protection concerns arise that are so acute as to require an emergency response. However, should such circumstances arise, and an urgent, out-of-hours contact need to be made with Social Services to report concerns, the following procedures apply: A clinical supervisor or senior clinician must be contacted before taking any action. Either the Director of Clinical Services or a Head of Clinical Services, or the Chief Executive of TCCR, or a head of training or another therapist in a senior position, must be consulted. If the outcome of this discussion is that it is felt that the concerns cannot wait until the next working day, then the senior clinician should phone the relevant local authority (where the family lives) and ask for the Out of Hours Emergency Team. The team local to TCCR (Camden) is on 0207 278 4444. If there are difficulties in getting through, and the situation is judged to be an emergency, the Child Protection Team should be contacted. For Camden, the telephone numbers are 0207 388 6953 or 0207 725 4547. Version 1 (April 2015) 50 5.2.17 Supporting staff Dealing with concerns about child protection can be very stressful for the therapists involved. It is very important that extra support is available through the process, and therapists involved in these processes should discuss their needs with their supervisor and/or a Head of Clinical Services or the Director of Clinical Services. 5.2.18 Implementation of the policy and training requirements This policy will be made available to all clinicians through the TCCR handbook. The content of the policy will also be communicated through training and supervision. The Director of Clinical Services will ensure that child protection training is available and that all supervisors address this with their supervisees on a regular basis. The needs of therapists in this area will be reviewed annually, as part of the process of review and appraisal that is mandatory for all clinical therapists. 5.3 Safeguarding vulnerable adults: policy & procedures 5.3.1 Introduction In this section we outline the duty and responsibility of all staff and students when working on behalf of TCCR with vulnerable adults. This policy also provides clear procedures that will be implemented where vulnerable adult protection issues arise. The overall responsibility for ensuring the implementation of effective procedures for safeguarding vulnerable adults rests with the CEO, but the Director of Clinical Services, in conjunction with the Heads of the Clinical Services, have day-to-day responsibility for ensuring that the procedures set out in this policy are being followed. All staff working with vulnerable adults have a responsibility for ensuring that they read and understand the principles within this procedure and that they undertake training where appropriate, to ensure they remain vigilant about the possibility of adult abuse. The procedures laid out in this policy are designed to ensure that: The needs and interests of adults at risk are always respected and upheld. The human rights of adults at risk are respected and upheld – all adults have the right to be safe from harm and must be able to live free from fear of abuse, neglect and exploitation. A proportionate, timely professional and ethical response is made to any vulnerable adult who is at risk or who may be experiencing abuse. 5.3.2 What do we mean by ‘vulnerable adult’? A vulnerable adult is described in “No Secrets” (2011) and “In Safe Hands” (2011) as a person (over the age of 18 years old) “who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation”. Many vulnerable adults may not realise that they are being abused. An elderly person who accepts that they are dependent on their family may feel that they must tolerate losing control of their finances or their physical environment. They may be reluctant to assert themselves Version 1 (April 2015) 51 for fear of upsetting their carers or making the situation worse. The Law Commission in its consultation document “Who Decides” (1997) suggested that “harm” must be taken to include not only ill-treatment (including sexual abuse and forms of illtreatment which are not physical) but also “the impairment of, and avoidable deterioration in, physical or mental health; and the impairment of physical, intellectual, emotional, social and behavioural development”. Although the primary responsibility for safeguarding all vulnerable adults falling within this definition remains with the local Social Services authority, safeguarding is regarded as everyone’s business and, as such, TCCR, in common with all other organisations working with vulnerable adults, also has responsibilities towards this particular client group. 5.3.3 Defining abuse “Abuse is a violation of an individual’s human and civil rights by another person or persons. Abuse may consist of a single act or repeated acts. It may be physical, verbal or psychological, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it.” (No Secrets, 2011) There are many different forms of abuse. These may be isolated or ongoing incidents, and may take place as the result of deliberate intent, negligence or ignorance. They can include, but are not necessarily limited to, the following: Physical Abuse: including hitting, slapping, pushing and kicking, misuse of medication, restraint or inappropriate sanctions. Sexual Abuse: including rape and sexual assault or sexual acts to which the vulnerable adult has not consented, or could not consent or was pressured into consenting. Psychological/Emotional Abuse: including emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or supporting networks. Neglect and Acts of Omission: including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services and withholding the necessities of life (i.e. medication, adequate nutrition and heating). Research has shown that neglect is the most prevalent form of abuse of elders in the UK, with financial abuse a close second. Discriminatory Abuse: including ageism, racism, sexism, that based on a person’s disability, and other forms of harassment, slurs or similar treatment. Financial or Material Abuse: ranging from a failure to access benefits through inadvertent mismanagement and opportunistic exploitation, to deliberate and targeted abuse, often accompanied by threats and intimidation (Help the Aged, 2008). It can include theft, fraud, exploitation, pressure in connection with wills, property and inheritance or financial transactions, overcharging or carrying out unnecessary work, or the misuse or misappropriation of property, possessions or benefits. It is important to remember that abuse can be perpetuated by one vulnerable adult towards another and this also needs to be dealt with accordingly. A vulnerable adult may also be neglecting him/herself and this too could be regarded as abuse. Version 1 (April 2015) 52 There are also a number of characteristics that may increase the risk of abuse, e.g.: Records of previous abuse or suspected abuse to the client. Previous abuse to other members of the client’s family. Among other factors shown to predispose individuals to abuse are advanced age (75+), being female, organic brain injury, cognitive impairment, physical, mental or emotional dysfunction especially depression, recent loss of spouse, social isolation, living alone and being estranged from one’s children. Vulnerable adults may be abused by a wide range of people including relatives and family members, professional staff, paid care workers, other vulnerable adults, volunteers, other staff users, neighbours, friends, associates, people who deliberately exploit vulnerable people, strangers and opportunistic people. 5.3.4 Procedure If during an initial consultation or treatment session the clinician becomes concerned about the possible abuse, neglect or exploitation of a vulnerable adult, it will be necessary to sensitively and appropriately explore your concerns. The purpose of this is to gather enough information to decide if the vulnerable adult is in immediate danger or, if not, to enable a decision to be made regarding a referral to an appropriate agency, i.e. Adult Social Care services. The seriousness or extent of abuse is often not clear when anxiety is first raised. It is therefore important, when considering the appropriateness of intervention, to approach reports of incidents or allegations with an open mind. In making any assessment of seriousness the following factors need to be considered: The vulnerability of the individual. The nature and extent of the abuse. The length of time it has been occurring. The impact on the individual. The risk of repeated or increasingly serious acts involving this or other vulnerable adults. If, however, you feel that the adult is in immediate danger, then it may be necessary to call an ambulance if there is a need for emergency medical treatment, or to consider contacting the police if a crime has been committed. However, these decisions will be made with reference to the Head of Clinical Services (Quality Assurance and Standards) in the first instance or, if unavailable, the Director of Clinical Services or another senior member of the staff team. In situations where the adult is not deemed to be in immediate danger but there are concerns, this must be discussed with the Head of Clinical Services (Quality Assurance and Standards) in the first instance or, if unavailable, the Director of Clinical Services or another senior member of the staff team, so that a decision can be made about contacting the relevant Adult Social Care services (or the Emergency Out of Hours Team), since they have the responsibility to investigate. Where a member of our staff or student body is concerned that another member of staff or student is abusing a vulnerable adult, they must follow TCCR’s code of ethics and act appropriately and with sufficient speed. This may involve talking directly to the colleague and Version 1 (April 2015) 53 raising the matter with a supervisor or their line manager. TCCR’s whistleblowing policy is also relevant here. Please note that if the person causing the harm is also an adult at risk, you should arrange for another member of staff to attend to their needs and make sure that other service users are not placed at risk. If it is felt that the adult at risk may not have the capacity to understand the relevant issues and to make a decision, it should, as far as possible, be explained to them and, if appropriate, they should be given the opportunity to express their wishes. In the event of the adult at risk not having the capacity to make a decision, relevant decisions and/or actions must be taken in the person’s best interests. However, these must be taken in conjunction with the Head of Clinical Services (Quality Assurance and Standards) or the Director of Clinical Services. In regard to the person alleged to have caused the harm, or where there is actual evidence of the harm having been caused during the initial consultation or treatment session, then it may be necessary to consider liaising with the police regarding the management of the risk and any direct police involvement. Again this decision will be made in conjunction with the Head of Clinical Services (Quality Assurance and Standards) or, if unavailable, the Director of Clinical Services or a senior member of the staff team. If there is any doubt about the mental capacity of an adult at risk to make decisions about their own safety, remember to assume capacity unless there is evidence to the contrary. If the adult at risk has capacity and does not consent to a referral and there are no public or vital inherent considerations, they have the right to reject offers of assistance and refuse interventions. However, in this event you should provide them with information about where to get help if they change their mind, or if the abuse or neglect continues and they subsequently want support to promote their safety. The assessing therapist must assure themselves that the decision to withhold consent is not made under undue influence, coercion or intimidation. 5.3.5 Risk assessment in safeguarding vulnerable adults Risk assessment is integral to the whole process of safeguarding and is specifically concerned with the identification of specific risks to a person covered by the Safeguarding Adults policy and procedures. A risk assessment seeks to determine: What the actual risks are – the harm that has been caused, the severity of the harm, and the views and wishes of the adult at risk (or an appropriate other adult or guardian if the adult lacks capacity to consent). The person’s ability to protect themselves. Who or what is causing the harm. Factors that affect the risk, e.g. personal, environmental or relationship factors that increase or decrease the risk. The risk of future harm from the same source. 5.3.6 Conclusion This policy is designed to protect the needs of vulnerable adults within the services provided Version 1 (April 2015) 54 by TCCR. It should be read in conjunction with the Intimate Partner Violence, the Codes of Ethics and Practice and the Whistleblowing Policy outlined in the TCCR Handbook of Policies & Procedures (2013). In safeguarding vulnerable adults it is vital that those who may be at risk are enabled, to the best of their abilities, to make decisions relating to their own health and welfare. The capacity to do this must always, therefore, be presumed, and a client can only be seen as lacking capacity if it is clear that, having been given all the appropriate help and support, they cannot understand, use or weigh up the information needed to make a decision. In situations where there are concerns it will be necessary, in conjunction with the Head of Clinical Services (Quality and Assurance), or the Director of Clinical Services, to establish whether a referral to the Adult Social Care services, or contact with the Police or NHS Emergency Services, are needed. Ultimately we all have a responsibility to ensure the safety and protection of vulnerable adults, and this policy and procedure outlines the ways in which, as an organisation, this can be achieved. 5.4 Clinical emergency procedures These procedures are for when you are concerned about a potential or actual emergency during a session. 5.4.1 Warren Street and New Street If you are worried that physical violence is about to erupt, or it has already done so and you are concerned for your safety or that of the clients in the session, then: In the first instance you may have the time to consider whether the session can be finished early. If this is possible then you may be able to help the couple consider how they will manage after they leave the building. Another possibility may be for you to leave the room and get some help to end the session. If it is not possible to negotiate an early end to the session and you feel unable to manage the situation alone, then help can be summoned by activating one of the emergency pagers. These are available from Reception and will need to have been collected prior to your session. The receptionist will note down the room number and time of all pagers currently in use (so that if one goes off, they will know where it is). The pager is silent at source, but will alert Reception that there is an emergency. When a therapist collects a pager from Reception, the receptionist must make a note of who has taken it and which room they are using. The receptionist must also find out who the senior member of staff is in the building, and which office they are in. 5.4.2 Pager alarm activation (a) Daytime up to 6pm In the event of a pager being activated, the receptionist (i) ascertains in which room support is required, and (ii) must immediately alert colleagues and senior therapists. In the first instance the Chief Executive and Director of Clinical Services must be interrupted in whatever they are doing by the receptionist. If they are not available, other therapists in the Version 1 (April 2015) 55 building must immediately be alerted and interrupted in sessions if necessary. The receptionist and at least one other colleague, a therapist, go to the room where help is required and establish whether the Emergency Services are needed. If this is the case then the receptionist goes to telephone the Emergency Services on 999, stating which service is required. The receptionist must be on hand to meet them when they arrive and show them where to go. (b) Evening 6pm-10pm In the evenings senior staff may not be available. If it is after 6pm and no senior therapist is in the building, then the receptionist must interrupt a clinician and ask for help. Again, if together they determine that the Emergency Services are required, the receptionist must telephone them, and meet them once they arrive. In all cases, where it is assessed that the Emergency Services are not required, then support will need to be given to the therapist needing help, to end the session and enable the couple to leave the building safely. If the receptionist is alone in the building apart from one clinician, who has activated the alarm, then the receptionist must telephone the police before leaving the reception desk. Once this has been done, and help is on its way, then the receptionist goes to the room where the therapist is to ascertain the situation. If things have calmed down, or if it is judged that emergency services are not required, then the receptionist goes downstairs and telephones the police again to tell them that police assistance is no longer required. They may come anyway, and it is important that the receptionist is on hand to let them in and explain the situation to them. 5.4.3 Following an incident A member of staff, practitioner or trainee who has a concern about actual or possible violence of any kind must immediately inform their supervisor, who will inform the Director of Clinical Services or whoever is deputising for him/her. Following an incident the practitioner will need to make a record of the session, clearly detailing the facts that led to the emergency. The Director of Clinical Services will arrange an internal planning discussion as soon as possible after receiving the record, and will prepare a report detailing the incident, any consultation undertaken, with whom and to what end and any actions taken, including the reasons for them. 5.4.4 Risk in ongoing cases With ongoing cases where you have a concern about your safety or that of your couples, you need to monitor this in discussion with your supervisor, who will consult with the Director of Clinical Services. 5.5 Complex case log To improve the quality of our services, a Complex Case Log is kept and monitored. Complex cases include any high-risk case, any case with a combination of more than one risk factor, and a case that demands an unusually high investment of time from clinical staff (e.g. discussions, extra supervision, phone calls and reports to external agencies). If you have a complex case, after discussion with your supervisor please complete a Complex Case Log Form (see Appendix 9), available from the Clinical Services Administration Manager. The completed form should be sent to the Head of Clinical Service (Quality and Assurance). Version 1 (April 2015) 56 6 OUTCOME MONITORING Throughout the course of therapy at TCCR, clients are asked to complete clinical questionnaires. This enables us to measure their progress in terms of general psychological distress and relationship satisfaction, and alerts us to particular risk factors. 6.1 The measures (a) Measuring symptoms in the general services (i) The CORE system: Clinical Outcomes in Routine Evaluation The CORE-OM (see Appendix 10) is a client self-report questionnaire designed to be administered before and after therapy. The client is asked to respond to 34 questions about how they have been feeling over the past week, using a five-point scale ranging from “not at all” to “most or all of the time”. The items cover four dimensions: subjective well-being; problems/symptoms; life functioning; and risk/harm. The responses are designed to be averaged by the practitioner to produce a mean score to indicate the level of current psychological global distress (from “healthy” to “severe”). Comparison of the pre- and posttherapy scores offers a measure of “outcome” (i.e. whether or not the client's level of distress has changed, and by how much). Since its development, CORE-OM 34 has been validated with samples from the general population and NHS primary and secondary care. TCCR are not using the clinician version of the CORE. (ii) The CSI: Couple Satisfaction Index The Couple Satisfaction Index (Funk and Rogge, 2007; see Appendix 11), is a standardised assessment of relationship satisfaction, consisting of 32 self-report items. These are scored on a five-point scale, with higher scores denoting higher relationship satisfaction. The CSI takes a different approach to measuring relationship quality from many other scales. It attempts to assess satisfaction and dissatisfaction in the relationship separately, rather than assuming that satisfaction and dissatisfaction lie at either end of a continuum. It therefore includes a series of statements asking people to reflect on positive and negative aspects of the relationship, e.g. “Do you enjoy your partner’s company?”, “I sometimes wonder if there is someone else out there for me,” or “My relationship with my partner makes me happy.” The scale also tries to capture how respondents feel about the relationship by inviting them to respond to a series of contrasting adjectives such as “interesting … boring”; “full … empty”. The CSI replaces the GRIMS as from September 2014 (but those who started with the GRIMS will continue to receive it). (b) Measuring experience of service (i) Experience of Service Questionnaire This questionnaire (see Appendix 12) is used routinely to measure client experience. The items give an indication of how clients experience coming to TCCR for therapy. They are asked to respond to statements such as “I felt that people here cared,” “I felt listened to.” Clients need to state how true they feel the proposed statements about the service are. In addition, the questionnaire provides an opportunity to answer open questions about the service they received here. Version 1 (April 2015) 57 (ii) End of Sessions Questionnaire This is a post-treatment questionnaire designed to capture both therapeutic change and the clients’ experience of the therapy. (iii) Schedules and measures Table 1 explains when the measures are given to clients in the general clinical services. Table 1: Measures at different time points in the general services Time point in therapy The measure Just before the first consultation appointment CORE 6 weeks after commencing regular ongoing therapy CORE CSI (Together with the Intake Questionnaire and Equal Opportunities Questionnaires) CSI Experience of service questionnaire 3 months after commencing regular ongoing therapy CORE 6 months after commencing regular ongoing therapy CORE 9 months after commencing regular ongoing therapy CORE 12 months after commencing regular therapy CORE Every 6 months ongoing up to 30 months after commencing regular ongoing therapy CORE Ending of therapy End of Sessions Questionnaire CSI CSI CSI CSI CSI CORE CSI Please be mindful that projects such as Parenting Together (PT), Parents in Dispute (PID) or Parents as Partners may use different measures. Please consult the relevant Head of Project. Version 1 (April 2015) 58 6.2 Using clinical measures to monitor outcomes The information we gain from the completed questionnaires is important both for the clinical management of our clients and organisationally in demonstrating the benefit of couples therapy at TCCR. It is therefore a requirement that all therapists comply with the following procedures. (a) Time point: consultation appointment All clients are asked to attend 15 minutes prior to their first consultation in order to complete the questionnaires. When the clients arrive, reception will give the forms to the clients to complete in the waiting area. The clients will hand these back to the receptionist when they have finished. As mentioned in the chapter on the initial consultation, when you go down to reception to collect your clients you should collect the completed forms from the receptionist. While you are collecting the couple, if possible look at the risk items on the CORE Form, those that are followed by an “R” on the right of the questionnaire. Invite couples to tell you about their experience of filling out the forms, as this will help open up possible areas of concern. After the consultation, please return all forms to the receptionist so they can be entered into the system. Reception will enter the data from all the forms into the STATA database. If the client indicates any degree of risk on the CORE questionnaire (i.e. scored above 0 on any of the risk items), Reception will alert you by: Completing a Risk Identified Form (see Appendix 13) Emailing you to alert you (see Appendix 14) The CORE, CSI and intake questionnaires will be filed in the case file within 48 hours of the date of the consultation. The Equal Opportunities Form is not filed in the case notes, but is destroyed once the information is entered into our database. If any disability issues are raised on the Equal Opportunities Form, reception will email you to alert you to the disability disclosed (see Appendix 15). (b) Time point: during regular ongoing therapy Once the couple have commenced regular weekly therapy, the CORE and CSI are issued to the clients at set intervals (see Table 1 above). When the forms are due to be issued to you, the reception team will put a copy of each clinical measures form and a covering letter (see Appendix 16) into an envelope. If it is a couple there will be an envelope for each client. Each form will have the case ID and the time point (e.g. six weeks, three months) printed on the bottom of the form. On the outside of the envelope will be the following information: Time point (Case ID) Name of therapist(s) Date to be given out The envelope will be inserted into the file and the fly sheet on the inside of the file (see Version 1 (April 2015) 59 Appendix 17) will be completed by the receptionist to record the date issued and the date inserted. On the date that the forms are due, hand the forms to the clients to complete and return at the next session. You should complete the fly sheet to record the date you gave out the forms. If the clients give the forms back to you, please check that they have completed the section with their gender and initials, as Reception will need this information. Please be mindful that some of the items can be emotionally stirring. It is good practice to ask the clients how they felt about completing the forms and whether they had any thoughts and feelings about it. The completed forms should be given to Reception for the data to be entered into STATA. The forms will then be placed back in the file in the “Forms” section and the fly sheet will be completed with the date they were returned. If a client has indicated any degree of risk (i.e. scored above 0 on any of the risk items) reception will alert you to this by attaching a Risk form to the front of the forms and by an email alert. Due to the importance of these forms, a reminder notice is issued if the forms have either not been issued by therapists or not returned by clients. The reminders are issued eight days after the date the forms were due to be given out. When it is the case that clinicians have not handed out the questionnaire to clients, therapists will receive an email reminder into which the Head of Clinical Services (Quality and Assurance) is copied. Where questionnaires are not handed out to clients, the Programme Head (if the therapist is a student) and Supervisor may be informed. The fly sheet is completed to record that a reminder has been issued. The following flow chart summarises the outcome monitoring procedure for ongoing sessions. Version 1 (April 2015) 60 Flow Chart to illustrate the outcome monitoring procedure in ongoing sessions Forms are placed in client folders by Reception. Reception checks to see whether forms have been returned. If forms have not been returned, Reception checks the client files. 8 days after form should have been handed out If forms have been handed out by clinician If forms have not been handed out by clinician Clinicians receive a paper reminder in the client folder to ask clients to bring the forms back. Clinicians are emailed to remind them to hand forms out at next opportunity, or to provide a reason why they should not be given out. Reception checks to see whether forms have been returned. If forms are not listed as returned, Reception checks client files. If forms have been handed out by clinician If forms have not been handed out by clinician Clinicians receive an email to remind them to ask clients to bring the forms back. Clinicians are sent a reminder. If only one client has returned the forms when there should be two, issue a reminder. Version 1 (April 2015) 61 (c) End of therapy forms When clients finish therapy they are asked to complete a final set of forms (CORE and CSI), plus an End of Sessions Questionnaire (see Table 1 in Section 6.1). The forms to be given out at the end of therapy are at the back of the case file in a clear plastic wallet. There is a set for each client. Use of forms for a planned ending to therapy A planned ending is one where it is agreed in advance with the couple that the therapy will end on a certain date. In this situation the following procedure should be adhered to: Before the penultimate session check that you have a copy of the End of Session Questionnaires for both clients. Take the questionnaires out of the plastic wallet and give the forms to the clients in the session. Ask them to complete the forms and bring them back to the final session. Hand the completed questionnaires in to Reception, who will enter the data into STATA and place the forms in the file. When writing up the closing report, complete the appropriate section to say the forms were given out at the penultimate session and the date of this session. You should also complete this information on the fly sheet. In the rare case that you feel it is not appropriate to issue the End of Session Questionnaires to clients during their penultimate session, please record the reason for this in the box provided on the closing report. This will be reviewed by a Head of Clinical Services. If you merely forgot to give out the questionnaire in the session please make a note of this so the administrator is prompted to post the forms to the clients. Use of forms for unplanned ending to therapy Where there has been an unplanned ending and you have been unable to give the questionnaires to the clients, please note this in the appropriate section of the Closing Report and request that an administrator post out the questionnaires. The administrator will complete the inside fly sheet to say the questionnaires have been posted. If it is not appropriate to send out the questionnaires, please record the reason for this in the box provided on the Closing Report. If the clients have not returned the End of Session Questionnaires after three weeks, Reception will send them a reminder and a further pack of forms. Version 1 (April 2015) 62 7 7.1 ENDING AND FILE CLOSURE Planned ending: steps to follow When a planned ending has been agreed, as soon as possible notify Appointments and Finance of the date of the last session. For psychotherapy cases a final invoice can then be prepared and issued to the clients prior to the last session so any outstanding fees can be paid before the clients leave. 7.1.1 The penultimate session Give the End of Session Questionnaires to the clients (these are located in the clear plastic wallet at the back of the file). Ask the clients to complete the forms directly after the session, or alternatively to return the forms at the final session. At the penultimate session psychotherapists also give out a final invoice, which includes the fee for the last session. 7.1.2 The final session Check that clients have completed the End of Session forms. If they give the forms to you, make sure you pass these on to Reception for processing rather than placing them in the file. If the clients have forgotten to bring the forms, ask them to complete them after the session (replacement copies are available in Reception). Explain that their feedback is very important to us. Make sure that the clients have settled any outstanding invoices (psychotherapy). 7.1.3 After the sessions Complete a Closing Report (see Appendix 18) within one week of the last session. Please type the form, ensuring that you are writing in a coherent way so that if the couple comes back in the future the next therapist is able to understand how the therapy ended and the main themes of the work. Fully complete the form and follow the guidelines on the form about what should be included. If applicable and agreed with the couple, please write to the GP/referrer/involved agencies, to let them know that the case is now closed. Make sure that the file is in order and complete. Check that all sessions are recorded, all Clinical Review Summaries are on file and all forms and emails are correctly filed in the relevant sections. Place the file in the administration closing tray. 7.2 Unplanned ending: steps to follow An unplanned ending is when the clients have not agreed an ending date with the therapist. It is usually helpful to write to the couple, inviting them to come to another session as an opportunity to say goodbye and think about the sessions they have had. Please provide a date by which they need to confirm their attendance. The clients should usually be offered their usual slot the next week. If they do come, please follow the steps mentioned above for a planned ending. Please be mindful that an unexpected ending or DNA (Did Not Attend without notification of cancellation) may indicate an increased risk. It may be useful to try to initiate contact again, Version 1 (April 2015) 63 inviting the clients to one more session “as an opportunity to think about the therapy and the current situation”. In cases of high risk, if any other agencies are involved (e.g. GP or Social Services) please consult your supervisor as it may be important to contact those other services. Once it has been established that the therapy has ended in an unplanned way (please wait no more than two unattended sessions and one week after contacting the clients), please follow the following steps: Notify Appointments and Finance that the case has ended. Give the date of the last session that needs to be charged. Request that the end of sessions forms are sent to the clients by post. If any fees are due, request Finance to send an invoice to the clients. Complete a Closing Report (see Appendix 18) within one week of the last session. As with a planned ending, please type this and complete all the sections clearly so that if the couple comes back in the future the next therapist is able to understand how the therapy ended and the main themes. Make sure that the file is in order and complete. Check that all sessions are recorded, that all Clinical Review Summaries are on the file and that all forms and emails are correctly filed in the relevant sections. Place the file in the administration closing tray. Version 1 (April 2015) 64 8 8.1 FINANCE Understanding TCCR’s fee structures The fees agreed by clinicians need to reflect our clients’ ability to pay in a way that is fair to them and to us as an organisation. Fees must be set at a level that enables clients to engage according to their needs in open-ended therapy. TCCR’s fees policy encourages those with means to pay a fee that subsidises those without means so they can access our services. 8.1.1 The fee for the consultation Our policy is to charge about twice the fee agreed for ongoing therapy – up to a maximum of £200 – for a consultation session. This takes into account the extra time and administration involved in the consultation process, and the letter sent to the couple before the consultation does explain this. You can, however, negotiate a fee that is realistic for the couple to pay. This needs to reflect our clients’ ability to pay in a way that is fair to them and to the organisation; it must be set at a level that enables them to engage according to their needs in open-ended therapy. TCCR’s fees policy encourages those with means to pay a fee that subsidises those without means so they can access our services. 8.1.2 The fee for ongoing sessions The email confirming a couple’s consultation appointment provides an outline of our fee guidelines for ongoing sessions. The formula we use to guide the negotiation of a weekly session fee is £2 for every £1000 of joint annual gross income – up to a maximum regular session fee of £180. If a couple are living on investments or other assets, or have particular financial pressures, you will need to make a judgement about the fee in discussion with them. Often clients have not taken in the formula, so it may make sense to start the fee negotiation by spelling out the formula above. If the couple tell you their gross annual income you can do a quick calculation yourself to start the negotiation. If they are not happy to say how much their gross income is you should not press them to reveal this, but you can ask them roughly what level of payment the formula would place them on. Please note that the formula is just a guideline. It should only be used as a basis for beginning the process of negotiating an affordable fee. Thus for a couple who have several children and a large mortgage, and who are supporting elderly parents, you may need to adjust the calculated fee downwards. The fee should be manageable for the couple and take into account the needs of the organisation. If they pay less than £80 per session, TCCR will be subsidising the therapy. It may be useful to refer to this threshold, and to the fact that TCCR is a charity. There is a balance to strike between the couple paying an appropriate rate for a high quality service and their realistic ability to sustain what might be a long-term therapy. If a fee is set outside the guideline figure of £2 for every £1,000 of income, give a clear rationale for this in the Consultation Report. When couples are paying a high fee this can bring anxiety for the therapist, particularly if the therapist is a student who is aware that couples may be paying more than they would in private practice. It is important to understand that this is because we are very explicitly operating a “Robin Hood” service – whereby those paying at a higher rate are helping the organisation to offer a service to people regardless of their capacity to pay. This commitment is to all our clients. Fees can be revisited in the course of therapy and increased or decreased should Version 1 (April 2015) 65 circumstances change. Our aim is to sustain a longer-term commitment to our clients, and our commitment is to continue to see people who need our help, whatever they can afford. Be mindful that it may be difficult for couples to discuss the fee, particularly when they are emotionally stirred up, and it is very important that you leave sufficient time for discussion. The fees discussion may, for instance, reveal an ambivalence about commitment to therapy that has not emerged earlier in the session, and you need time to think about this with the couple. Remember that fees are capped at £200 for a consultation appointment and £180 for each regular session. 8.1.3 Low-fee clients Clients must usually pay a minimum of £50 per session for evening appointments. In exceptional circumstances we may be flexible about this, but it is important that therapists think carefully about this. If, for example, the clients are not working full-time and so are paying a low fee and yet are asking for an evening vacancy, this needs to be questioned before any agreement is made, as do any similar requests. If the clinician agrees a fee lower than £20 for daytime appointments, the clinician must fill in a Low Fee Form (see Appendix 4). This form asks the therapist to explain the reasons for the low fee and must be approved by a Head of Clinical Services. This procedure helps ensure that only cases that really need a low fee are taken in on that basis. Evening psychotherapy appointments are unlikely to be available unless clients are paying an ongoing session fee of at least £80. 8.1.4 Payment for missed appointments You will need to explain TCCR’s missed session appointment policy. Explain that the couple will be allocated a specific time for regular weekly sessions, and it is unlikely that this time can be rescheduled in the course of the work. Also explain that if they have to miss a session they will be expected to pay. You can mention that the ongoing therapist may agree to see one partner if the other is away and cannot get to a session, but this will need to be discussed with the ongoing therapist. The obligation to pay for missed appointments might provoke an adverse reaction. As with other aspects of the consultation, you should try to explore what it might be stirring up for the couple – this may help later, in your formulation. It is essential that you, as an assessor, understand and sit comfortably with the idea of paying for missed appointments. Paying for missed appointments creates a regular commitment that is important for the therapy and enables the regular therapist to establish a weekly time the couple can rely upon. TCCR expects its therapists to make a serious commitment to providing therapy on a regular basis, only cancelling for planned holidays or in the case of sickness. A matching commitment is elicited from clients, providing the basis for establishing a secure therapy. From the organisation’s point of view, it would be economically unviable for TCCR to waive the fee when clients cancel sessions. It is important to note that the room itself and the couple’s time with their particular therapist are booked until the work ends, and if they cancel the session the slot cannot be given to anyone else. 8.1.5 How clients can pay If the client wishes to pay by cash they should pay you in the room. For card payments please take them to the reception desk. American Express is not accepted. Version 1 (April 2015) 66 8.2 Debt management It is important for the financial viability of the organisation that all fees are paid in a timely fashion. Counselling and psychosexual clients pay for sessions weekly and psychotherapy couples are invoiced monthly in arrears. Client debt should not accumulate and TCCR clinicians are expected to discuss any outstanding debt with clients. Please check the finance invoice issued prior to the session to see whether your couple/individual paid their fee. If debt accumulates or payments are delayed this is relevant to the clinical work and the meaning of this will need to be thought about and the issue taken up with the clients. If your clients are delaying payment,or debt is starting to accumulate, this must be discussed with your supervisor and the Clinical Service Heads should be alerted. . 8.2.1 Ceilings for outstanding debt TCCR sets limits on how long clients can remain in debt to us. These are as follows: Counselling: no more than three weeks. Psychotherapy: no more than two months. Should these targets not be met and there are no exceptional mitigating circumstances, you should consider in consultation with your supervisor whether the couple should continue to receive treatment. 8.3 Annual revision of fees The fee for ongoing therapy is usually agreed in the initial consultation session. However, it is important to review it during the therapy as clients’ financial circumstances may have changed since the consultation session. In addition to the ongoing review of the appropriateness of the fee, at the start of each new financial year (1st April) fees are reviewed in line with inflation. Therapists should initiate a discussion with all cases that have been attending ongoing sessions for over six months. You will be advised at what percentage increase we are setting the annual fee uplift (this figure will take into account current inflation, RPI, etc.) All cases, unless there are exceptional mitigating circumstances, are expected to increase their fees by this amount each April. Again, you would need to balance exploration of the couple’s reaction to this with a firm stance, to apply the percentage uplift to their fee and then round it up so that it is a sensible figure which is not too fractional. You will be reminded ahead of time of the need to discuss the annual fee uplift with all of your clients, and advised of the annual uplift amount. You will also be issued with a form (see Appendix 19) which you need to complete, confirming the agreed fee and that you have notified Finance of any changes. If you have a couple whose fee you and your supervisor have agreed should not be increased, you should document the reasons for this on the form. This form should be signed by your supervisor and handed in for the attention of the Director of Clinical Services. 8.4 Invoicing for services 8.4.1 Counselling For counselling and psychosexual services, client invoices (see Appendix 20) are printed each night and filed in your clinical file slot ready for your session the next day. The invoice Version 1 (April 2015) 67 shows the client names, location of the session and the clinical service. The top section of the invoice shows any outstanding fees from previous sessions. The middle section shows the sessions due for today. After the session you should complete the lower section of the form, which asks you to say whether the client attended today and to provide details of payments made. The completed form should be put with any cash or cheque payment, and the pink copy from your receipt book, in the safe in a sealed clear plastic bag (found on top of the safe). We are able to take payment by credit or debit card (please note that we do not accept American Express). If clients wish to pay by card, write out the receipt and give the white copy to the couple to give to Reception. The pink copy of the receipt should be put in the clear bag with the completed invoice. Seal the bag and post into the safe, making sure that it is fully pushed in. 8.4.2 Psychotherapy For psychotherapy, clients are invoiced monthly in arrears. A week before the end of the month, Finance will print the invoice on blue paper and file it in your slot. Please tick the dates you wish the clients to be invoiced for. Any additional information which Finance needs to be aware of should be written on the bottom of the blue form. Put the blue invoice in the drawer of the Finance Assistant, Dawn Pearson, in the administration office. Finance will then produce an invoice for the clients and this will be put into your file slot. Please check this invoice carefully and contact Finance if any further corrections are required. At the next session, issue the invoice to the clients for payment. If the client wishes to pay by cheque or cash they should pay you in the room. Write a receipt for the payment and give the clients the top white copy from the receipt book. The pink copy should be put in a clear plastic bag with the cheque or cash. If the clients wish to pay by card, give them the invoice and direct them to Reception, who will take the payment. NB: New receipt books can be obtained by contacting the Finance Team. Version 1 (April 2015) 68 9 CLINICAL FILES 9.1 File storage 9.1.1 Active clinical files All active clinical files are kept in a filing cabinet in the main administration office (ground floor Warren Street) or file room (New Street). Each therapist has a slot in the filing cabinet and files must be returned to the cabinets by the end of each day. The cabinets are locked each night. Under no circumstances are files to be stored in staff offices or any other place at either centre. On occasion files may need to be accessed by staff e.g. for audit. If anyone other than the allocated therapist needs to remove a clinical file, they must put a tracer card in the clinician’s slot (see Appendix 21) and must notify a member of the clinical administration team. Files must be returned to the file cabinet as quickly as possible and must definitely be returned to the slot at the end of the day. 9.1.2 Closed clinical files Once all closing procedures have been completed, the file is stored in the clinical archive for eight years. After this the file is destroyed. If a client returns to TCCR within eight years, the file is put in the assessor’s slot to review before the consultation. If the file is deemed relevant to the current provision of therapy, the date of archive storage is reset to the date when the current therapy ends. If the original file is deemed not relevant to the current therapy, the file is returned to the clinical file archive and is stored until eight years after the file was closed. 9.2 Transfer of clinical files Clinical files must not be removed from the building by therapists for any reason. If you need to transfer a document or file between our Warren Street and New Street centres, the TCCR clinical courier system must be used. 9.3 File organisation Files must be kept to the highest standards and be organised. At the front of each file is a Client Summary Sheet which contains name(s) and contact information. Behind the Client Summary Sheet are three documents: Clinical File Check List (blue form): this document should be used to communicate to clinical admin any changes in contact information. Consultation Guidelines (yellow form): This document offers guidance for the assessing therapist about key points of the consultation session. It is removed after the consultation process is completed. The rest of the file is organised into five separate sections: Consultation Reports: in this section you should file Consultation Reports, Supplementary Consultation Reports and Post-Consultation Review forms. Version 1 (April 2015) 69 Forms: in this section all questionnaire forms completed by the clients should be filed in date order (e.g. intake questionnaire, CORE, CSI). Case Record Summary: all session summaries should be written up in this section and all Six Monthly Summaries should be filed here. Session Summary Forms are available in the lobby and in the New Street Common Room. Please refer to the section on case notes in the “Treatment” section. Letters and Messages: copies of all letters, emails and messages are kept in this section. If you have a telephone call with a client you should write a note of the telephone call and what was said and file it here. Closing Reports: copies of the Closing Report, End of Sessions Questionnaire procedure and Closing Procedure are kept here for your reference. Copies of the End of Session Questionnaires are in a clear plastic wallet ready for the case ending. When you have closed a case you should type up the Closing Report and file the document in this section. It is important that you file documents in the correct sections as detailed above. Detached notes may be lost and present a confidentiality risk. Under no circumstances should documents from one case be filed in another case file. Make sure that all notes and documents in the file have the client ID on them (so that if a paper is detached from the file it is identifiable, and if the file needs to be photocopied all its papers are labelled). Version 1 (April 2015) 70 10 CONFIDENTIALITY AND DATA SECURITY The following is a summary of some of the key principles from the policies. This section must be read in conjunction with the Staff Handbook and the Code of Ethics and Conduct. 10.1 Confidentiality in the clinical encounter 10.1.1 Couple confidentiality versus individual confidentiality In couple therapy, when the couple come together to sessions it is important to discuss with them the fact that we generally assume that information can be shared between the couple if they are entering into couple therapy. This might not be obvious to the clients so must be emphasised and discussed. It is especially relevant on occasions when only one partner can attend, an event the couple may let you know about in advance. In some cases it might be not helpful for the couple for one partner to attend without the other. In other cases it may feel possible for one partner to attend without the other. It is important to consider what is right for the couple and to allow a discussion with the couple about their feelings about this. If only one partner is to attend, please initiate a discussion with both about what will happen to the information shared in the individual session. Remind them, if necessary, that the individual session is happening in the context of couple therapy. In the actual session with only one of them you can refer to the missing partner and facilitate thinking about their point of view. If, unexpectedly, only one partner comes to the consulting room, giving apologies on the behalf of the other, it is likely to be important to start the session with a discussion about this. You may say something along the lines of: “We haven’t had an opportunity to discuss this beforehand,” and take up the issue of confidentiality by saying, for example: “What happens with what you tell me? It is usually assumed that information can be shared between the couple, and our work here today is still in the context of couple therapy.” You can allow space for any discussions that emerge. Another point of possible difficulty is when the therapist wishes to discuss the outcome forms and any risk item that may have been checked. The forms are completed individually, so the therapists should always initiate a discussion about them with sensitivity to the issue of individual versus couple confidentiality. It is helpful if the discussion about the forms occurs in the context of, or after a discussion about, information being shared between the couple. It is important to discuss in very general terms how it felt to complete the outcome forms and whether there is anything they would like to say about this. If clients ask whether the sessions are confidential, please explain that part of our professional functioning involves discussing our work with colleagues but we do not disclose information about clients to external third parties. You could say that the exception to this is in situations where there is significant concern about harm to you or someone else and this would normally be discussed with you beforehand. 10.1.2 Confidentiality of clinical documents: critical principles No names or contact information should be contained in any clinical write-ups (paper or electronic). For Clinical Session Notes, Clinical Review Summary, Closing Reports, Consultation Reports, emails or any other clinical documents, only use client initials, first names and case numbers to identify the clients. No contact information should be included. Client contact information in Consultation Reports should be written by hand on site at TCCR at the time you are handing in your report. Under no circumstances should this report be saved anywhere with this contact information included. Version 1 (April 2015) 71 Client names should not be put on any invoices or claim forms for clinical work. Case numbers only should be used. Please make sure to use the new version of the Clinical Claim Form (revised September 2014). Copies are available in the lobby and Common Room. Clinical documents should only be saved to your TCCR-issued encrypted USB memory stick or on a secure area of the TCCR network. Under no circumstances should therapists save TCCR clinical documents to their own memory stick, devices, drop box or to any clouds. When creating, saving, and/or sending a Word document, clients’ details should always be anonymised (use initials and ID number only) and the document itself should be locked with a password. Any printed drafts of clinical reports, and any handwritten clinical reports, must be shredded as soon as they are no longer needed. Password protecting clinical documents Clinical documents should be password protected. Please choose a password that is at least 10 characters long, preferably mixing upper and lower cases, letters and numbers. If you are emailing the document never send the password with the document. You should always send the password in a separate email or text or call the recipient with the password. PC: To password protect a Word document on a PC, click on the “File” tab on the top tool bar. Select “Info” from the menu, then the “Protect document” icon to the left of “Permissions”. A further menu will open and you should select “Encrypt with password”. Enter the password carefully (you will be asked to enter it twice). Mac: To password protect a Word document on a Mac, open the document in MS Word. From the main menu at the top of your screen, choose the “Word” menu and then select “Preferences”. Click on the “Security” icon and provide a password in the blank section entitled “Password to open”. Enter your choice of password carefully and click “Ok”. You will be asked to re-enter the password. Be careful to remember your password or you will not be able to open the document in future. 10.2 Encrypted memory sticks All students, Visiting Clinicians and staff conducting clinical work must have an encrypted USB memory stick in order to do clinical work. The TCCR encrypted memory stick should always be kept in a safe place. Each memory stick should have a key ring with the device number and TCCR phone number on it. The Content of the TCCR memory stick must be actively managed. Make sure you delete clinical documents. Your TCCR memory stick should only contain current documents that you are actively working on. All documents saved on the memory stick must still comply with the above guidance on contact information and password protection. Therapists must permanently delete any clinical information stored anywhere other than the TCCR-issued USB memory stick (e.g. other memory sticks or devices). 10.3 Procedure for issuing TCCR encrypted memory sticks Students and visiting clinicians are asked to pay a £20 deposit, which will be refunded to them when the memory stick is returned to TCCR. When you are issued with your TCCR memory stick you will be asked to sign a declaration form (see Appendix 22) to confirm receipt of the memory stick and to confirm that: Version 1 (April 2015) 72 You will follow the TCCR protocols on use of memory sticks and confidentiality policies. You have no clinical documents saved on any other devices and you will only use the TCCR-issued encrypted USB memory stick to save clinical documents to whilst you are working on them. You understand that TCCR-issued USB memory sticks will be subject to audit. You have read TCCR’s policies on confidentiality and you understand that noncompliance will result in disciplinary action. If you have not received a TCCR encrypted memory stick, or you have any questions regarding the issuing of USB memory sticks, please contact TCCR’s Operations Manager, Sandra Winnick. 10.4 Process notes Process notes are detailed notes about the session usually written by trainees for the purpose of learning or by qualified clinicians for supervision. They are not considered clinical record notes for TCCR purposes. However as process notes discuss TCCR’s couples, their creation and storage should adhere to the highest standards of confidentiality. Process notes must: Be fully anonymised (either changing the names or using initials only). Not contain identifiable information (e.g. specific locations, professions). Trainees are encouraged to discuss what would constitute identifiable information with their supervisors. Supervisors can offer guidance in each case about the level of identification that can be disclosed in written work. The student may wish to speak to their supervisor or the supervision group about some factual details, such as the real occupation or specific location of the couple, as these might be clinically significant. The electronic document must be password protected, with ten characters mixing upper case and lower letters and/or numbers. The process notes must be permanently deleted as soon as they are no longer needed for training purposes. Any assignment which contains clinical material that is sent to any member of staff MUST be password protected using 12 characters of mixed upper case, lower case and numbers. If process notes are hand written or printed out, they must be stored in a safe place locked by a key. They should never be read or taken out in public places. Any hard copies of process notes, whether hand written or typed, must be shredded as soon as no longer needed. Please discuss any further questions about this with your supervisor. Version 1 (April 2015) 73 11 EMAIL USE: POLICY AND PROCEDURES 11.1 How to use email: good practice and risks This section tells you how to use email to communicate with clients and other staff or trainees. It also outlines some risks of misusing email. 11.1.1 Scope and responsibilities The procedure applies to all TCCR representatives, including all staff, trainees, visiting clinicians, third party contractors, work experience staff and honorary staff, whether working on TCCR premises or at home. Line managers are responsible for ensuring compliance with this procedure. 11.1.2 Guidance and procedures Communicating with clients via email The designated TCCR email account “Appointments” ([email protected]) is to be used for all emails to clients concerning appointments and factual, non-sensitive, nonpersonal material only. Only clinical administrators who are trained to use this account should handle emails to and from clients. This allows us to have a centralised record of all communication with clients. The only exceptions to this are Clinical Administrators or Heads of Clinical Services, and specific projects. The recipient’s email address should be checked at least twice, to ensure that the email is only sent to the correct recipients. All email correspondence with clients (including attachments), whether sent or received, must be printed and placed in the clinical file. If a therapist needs to send an email to clients, the therapist should draft the text of the email and forward it to [email protected]. They should follow this procedure: Do not use clients’ names. Instead use their initials. For example: “Dear A and B.” Put the case number in the subject field of the email. State clearly in the email to Appointments what you wish to happen. For example: “Dear Appointments Team, please send the email below to case number 54321.” If separate emails need to be sent to each partner separately to maintain the confidentiality of their email addresses from each other, please make this very clear. Send your email to [email protected] When writing emails to clients, please adhere to the following: All emails should be formally structured, starting with “Dear” and ending with an appropriate closing salutation. Do not assume that you can use first names with your clients without thinking about it first. Surnames are to be used in the initial contact. Always use respectful and clear language. Please avoid acronyms or jargon. Do not use only CAPITAL LETTERS. This may be regarded as rude or as shouting at someone. Red ink may have the same effect. (This applies to all emails and web communication.) Version 1 (April 2015) 74 Keep your email short and limit it to the matter at hand. Do not include interpretations of, for instance, missed appointments or premature endings as these may be received differently from your intention. Students must agree drafts of anything beyond a simple response to a cancellation either with their supervisor or, if they are not available, with the Director of Clinical Services or a Head of Clinical Services. Any emails that include clinical observations or interpretations must be authorised by a Head of Clinical Services or the Director of Clinical Services before being sent. In some circumstances (by prior discussion) this authority may be delegated by the Director of Clinical Services or Head of Clinical Services (Quality Assurance) to relevant Project Heads. If you need to communicate a more sensitive message to your clients, referring to material personal to them, please do so by post or via encrypted PDF or Word document. Clinicians must agree the content of such documents with their supervisor and seek authorisation as described above before the email is sent. Password protecting clinical documents Please see Section 10.1.2, above. Communicating between colleagues via email Under no circumstances should identifiable client data be sent by email without adequate protection against unauthorised access. When sending emails between staff, the case number ID should be used to identify the case (rather than names or any other personal data). When creating and sending a Word document, clients’ details should always be anonymised and the document itself should be locked with a password before it is sent. See Section 10.1.2 for guidance on how to password protect a Word document. Under no circumstances should TCCR-related emails and attached material be saved to Dropbox. If using a memory stick, make sure it is password protected, and that all confidential Word documents are protected. Staff may forward non-sensitive emails to other colleagues if necessary, but regard must be given to the security of these email accounts (e.g. shared email accounts or shared devices/PC). All staff, trainees and visiting clinicians using non-TCCR email addresses must only use a personal email account that is private and not shared with anyone else (including family members) and the account must be password protected. If personal devices are used, documents should be password protected at all times. This is in addition to the procedures above regarding removing identifying client data. If emails are accessed on personal devices (including smart phones), the device itself should be password protected. Mailing lists All electronic mailing lists (including those of clients, trainees, conference attendees or any other mailing lists) are absolutely private and confidential, subject to Data Protection Act 1998 requirements, and are considered the sole property of TCCR. Under no circumstances Version 1 (April 2015) 75 should past or present staff use any of these lists for non-TCCR purposes (commercial, private or other) or pass them on to a third party. Inappropriate and/or unrecognised emails Staff should not open or download inappropriate emails or emails containing material which may be considered libellous, pornographic, hostile, sexist, racial or inciting hatred to any religious or minority group. Staff should also not forward emails containing such material from TCCR to other email accounts. Staff should be careful not to download any material breaching copyright laws. If a user has any doubt about the origin of an email or attachment they received they should delete the email rather than risk infecting their device with a virus. Do not follow advice on virus removal offered online or in emails or when downloading files. Please contact [email protected] for further information. Remote access to e-mail When accessing emails via remote access, or when using mobile devices, users should ensure that they are using private rather than shared network servers (e.g. in cafés or hotels). Confidential material should not be saved on personal devices unprotected. Users should apply to their email the same code of confidentiality and care as they would if they were working on TCCR’s premises. Advice on good practice when handling e-mail accounts a) Please give consideration to whether it is necessary for non-clinical emails and their attachments to be printed before printing them out. b) Please exercise caution when disclosing contact details, especially your TCCR email addresses or contact details, to third-party organisations. This information may be passed on and generate junk mail or inappropriate emails. c) Do not write down your user name and passwords and avoid leaving your PC or device unattended. Ensure your settings automatically lock your screen after a set period of inactivity1. d) When sending emails to multiple recipients please be mindful not to share recipients’ email addresses without their permission. In some circumstances it is better to use the blind carbon copy (Bcc) option to protect their privacy2. This method is also useful should you wish to keep your recipients from knowing who other recipients are. e) Be mindful when using Outlook that calendar invitations do not contain any personal data. 1 Contact the Operations Manager if you have any queries. 2 To add a BCC field to an email in Microsoft Outlook 2010: click on the “Home” tab, click on the “New Email” icon. Click on the “Options” tab at the top of the email and under the “Show Fields” options click on the “BCC” icon. Version 1 (April 2015) 76 Managing your online profile in a professional context Please read this section in conjunction with “TCCR Media and External Relationships Policy and Procedures" in the Staff Handbook. It is important that therapists are aware that clients often search their therapist’s name online. Please check your online profile and make sure that the necessary restrictions have been placed on your social network profiles. While using social networking sites in a personal capacity, employees’ actions can still damage our reputation. Even in their personal communications, those who work at TCCR must not: Behave in a manner that would not be acceptable in any other situation. Bring the organisation into disrepute. Post or publish any sensitive or confidential information. Make comments that could be considered as bullying or harassment or as discrimination against any individual. Use offensive or intimidating language. Pursue personal relationships with clients or ex-clients of TCCR. Use social networking sites in any way that is unlawful. Post inappropriate comments about colleagues or clients. Post remarks that may unwittingly cause offence and constitute unlawful discrimination in the form of harassment. Comment on work-related issues. Let your use of social networking sites interfere with your job or commitment to clients. Professionally qualified staff may place their registration at risk if they fail to adhere to these guidelines. Media If a staff member is approached by the media, they should refer this to the Head of Marketing and Communications. Please do not say you are not allowed to talk to a journalist or have to get permission to do so. Instead, tell the reporter: “TCCR policy is to refer all media inquiries to the Head of Marketing and Communications. You can reach them at 0207 380 1975.” Version 1 (April 2015) 77 12 ESSENTIAL INFORMATION FOR THERAPISTS 12.1 Sickness and absence If you are unable to attend your regular session, for example due to sickness, it is your responsibility to let your clients know, with as much notice as possible, that the session is cancelled. You should contact the clinical administration team as early as possible to make them aware that you are unwell. The administrator will be able to give you the contact numbers for your couples so that you can call them to cancel the appointment. Once you have spoken to your clients, if you wish to send a follow-up email message you should draft the text and send this to the Appointments Team ([email protected]) who will forward your message (see Section 11 for email policy and procedures). 12.1.1 Extended absence In the case of a known extended period of absence on the part of the therapist: Discuss this with your supervisor and inform a Head of Clinical Services. Complete a Clinical Review Summary and place in the file. Record in the file the discussion with the clients about the break in therapy. The file must be updated with the next appointment and the clients’ understanding of alternative resources while the therapist is away. The file should be given to Appointments so our system is updated with the next appointment. Employed staff must adhere to the procedure for reporting and managing sickness absence that is set out in Section 10.2 of the Staff Handbook. Breaks in the therapy initiated by the clients must be paid for. In special mitigating circumstances this can be reviewed by a Head of Clinical Services. 12.1.2 Holidays Clients should be given notice of breaks well in advance. It is expected that your own holidays be taken out of term time and ideally at normal holiday times such as Christmas, Easter and August, when many clients also tend to be away. Therapists and students are not expected to take more than three weeks’ break at any one time. Any exceptions to this should be agreed with your supervisor, who should inform a Head of Clinical Services, and the guidelines about extended absence above must be followed. Before the Christmas and summer breaks, the clinical administration team will contact all staff to ask for their holiday dates. Any dates taken outside these holiday periods should be notified to the administrator using the Clinician Daily Record. The Clinical Review Summary must be typed, printed and filed before you go on holiday. 12.1.3 Continued Professional Development and mandatory training Please read this section in conjunction with the Continued Professional Development (CPD) policy in the staff handbook. All TCCR clinicians, supervisors and teachers/trainers are expected to meet the minimum post-qualifying CPD and supervision standards of relevant professional bodies (such as BPC, UKCP, COSRT & BACP). They are expected to be Version 1 (April 2015) 78 working towards accreditation if they are not already accredited. Standards for CPD include: maintenance of an up-to-date and accurate record of CPD activities; recording a range of CPD activities relevant to current or future professional practice; showing how development needs have been reflected upon, planned and evaluated and how these will have an impact on practice; the availability of a record upon request. It is expected that at least 12 hours of CPD per annum relates to couple work. For clinicians, Continuing Professional Development consists of keeping up-to-date with current scientific and clinical developments and ensuring that their clinical sensitivity and objectivity remain on a level adequate for fitness to practice and for the management of risk factors. All clinicians must ensure that they attend any mandatory training put on at TCCR as required. Supervisors are expected to attend a monthly agency supervisors meeting. They are expected to keep abreast of developments in supervisory practice and thinking. As dual professionals (with both a subject specialism and teaching and learning expertise), teachers and trainers are expected to undertake at least six hours teaching and learning CPD per annum. This may include: reflective practice; having the time and space to plan experimentation and to trial teaching and learning methods and review them (see www.ifl.ac.uk for CPD ideas). 12.2 Treating Admin and Reception with respect The clinical administration team is at the front line of TCCR. They are often under a lot of pressure dealing with difficult clients on the phone and answering a high volume of emails from clients and therapists, some of which involve clinical emergencies. They are also responsible for managing intake and allocation, all TCCR’s projects, the diary and room allocation. The training administration team also have a consistently high volume of work ensuring a high standard of delivery for three busy training courses and all Continuing Professional Development events. Reception staff attend to phone calls and clients at the desk. They also deal with outcome monitoring and intake forms, which involves following up and inputting as well as letting you know about any risk found on the CORE form. They do their work to the highest standards and we would like them to stay with us. Please ALWAYS treat all the administrators and receptionists with respect. Respect their space, and avoid using their stationery. Wait for them to finish the activity they are doing, especially when they are handling a telephone call, before making your enquiry or request. Please be polite and make your request or enquiry in a calm and respectful manner. 12.3 Dress code Therapists and staff are expected to dress appropriately for the work they are doing, and to maintain a working environment that conveys the professionalism and high standards of the organisation. Staff and therapists are trusted to use their judgement on what is appropriate for work within the general requirement that look smart and presentable. However jeans and trainers will not normally be regarded as appropriate clothing for clinical work and for any and all roles that come into direct contact with clients (clinical clients, students, visiting clinicians, etc.). Version 1 (April 2015) 79 Exceptions may be made by explicit permission from a member of the senior management team, e.g. if staff are due to perform tasks such as tidying up or moving furniture. In such cases more casual clothes may be worn. 12.4 Professional insurance All practising therapists at TCCR should arrange to have professional indemnity insurance. This would be also a requirement of most registering professional bodies. 12.5 Professional clinical titles 12.5.1 Use of professional titles by clinical faculty staff The title “Senior” is available for use where the faculty staff member has been qualified for at least five years and delivers clinical supervision in their modality within TCCR. The title “Consultant” is available for use where the faculty staff member has been qualified for at least ten years and is currently supervising (or has in the past supervised) within their modality at TCCR and is currently holding a key institutional role in relation to either clinical, training or research activities. 12.5.2 Use of titles by non-faculty clinicians and therapists When writing an email to clients who know you please sign with your name only. In formal communications please add your core professional title if applicable. 12.6 Information updates All staff, visiting clinicians, trainees and supervisors have a duty to remain up-to-date with any changes and updates in TCCR’s policies and procedures. This Clinical Handbook, the Staff Handbook and the weekly Essential Information Bulletin must be read and adhered to. Please contact the Clinical Services Administration Manager if you are not receiving the weekly bulletin or if your contact details change. Version 1 (April 2015) 80 13 APPENDICES 81 13.1 Appendix 1: Deposit Waiver Form Deposit Waiver Form If you wish to apply for the initial consultation deposit to be waivered, please complete the form below and email this document to [email protected]. There will be a fee to pay for your initial consultation appointment and all subsequent sessions. Our fees are calculated on a sliding scale according to income and your clinician will discuss with you at your initial consultation appointment what fee you can afford to pay for your sessions. Name(s) of Couple or Individual Please let us know either your annual or your weekly income (an estimate is acceptable): If you are in receipt of benefits, please specify: I/we would like to request that the £30 deposit for the initial consultation appointment is waived. Client Signature: Client Signature (partner): Date: 82 13.2 Appendix 2: Confirmation Email Dear Thank you for contacting The Tavistock Centre for Couple Relationships. This letter is to confirm that we have arranged a consultation appointment for you as follows: Time: Date: Venue: With: (see link to map below) Your Appointment Please arrive 15 minutes before the time of your appointment stated above and check in at Reception on your arrival. You will be asked to complete some brief questionnaires before your appointment. Please allow 90 minutes for your appointment. During this time you will have the opportunity to explain your concerns and to discuss how we may be able to help you. We have a range of services and during this initial session, the therapist will explore what kind of help would be most suitable. Subsequent sessions last for 50 or 60 minutes (depending on the service). TCCR is a centre of excellence for accredited training and as part of our commitment to professional development you may be seen by a trainee working under specialist supervision. Our Fees There will be a fee for this consultation session and for all subsequent sessions and this will be discussed during this initial session. TCCR is a charity and we aim to help everyone whatever their income, so there is no minimum fee and there is a maximum fee of £180 for ongoing sessions. The fee you agree will reflect your earnings and your wider circumstances. TCCR suggests a rate based on £2 for every £1,000 gross income- however this is only a guide and we always aim to agree a fair, affordable payment. The charge for your first consultation appointment will usually be higher than the fee for regular sessions. This reflects the longer time we spend with you and the careful work we aim to do in order to make sure you get the specific help you need. The maximum fee for your first consultation appointment is £200. If you would like more information about fees or have any other questions please see www.tccr.org.uk or call 0207 380 1960 to speak to one of our appointments team. We look forward to welcoming you to our services. Yours sincerely Appointments Team 1 of 2 83 Frequently asked questions TCCR Counselling and Therapy Service • Do I have to do anything before I come? No. Although you might find it useful to think about your situation and how you want counselling or psychotherapy to help. What has led you to seek help? What are the things you wish to change? Are there issues in your relationship currently or from the past that you are wanting to understand, or repeating patterns in your relationships that are causing you problems? These sorts of questions will be explored with you at your first appointment. • Can I bring my child? Although we understand that it may be difficult for parents to arrange childcare, we want to create a space where you and your partner can speak to each other freely, and so bringing your child into your appointment with you is not possible. In addition, TCCR does not have crèche facilities, and so it is not possible to leave children in our reception whilst you have your appointment. In the case of very small babies, it may be possible to bring them into the appointment, but this can be disruptive for you and make it more difficult to concentrate on the therapeutic work. • Is TCCR counselling and therapy confidential? TCCR’s therapists adhere to our professional code of ethical standards which includes the principle of confidentiality. This means that we would not disclose information about you to a third party without your agreement, except in situations where there was significant concern about harm to you or someone else and this would normally be discussed with you beforehand. If you come as a couple we would normally expect that information to be shared between you. If you have any questions about confidentiality you can discuss them with your therapist. • Do TCCR counsellors and psychotherapists have special training? Yes. TCCR is a centre of excellence for accredited training and research in couple relationships. All psychotherapists in the service have substantial experience and have undertaken or are undertaking, further postgraduate training in couple psychotherapy. They bring a wealth of clinical experience from a variety of related settings including social work and clinical psychology, and many are qualified in psychotherapy with individuals as well as couples. Similarly our team of counsellors undertake a very rigorous training, with substantial further supervised practice. This represents the highest standards of professional training in counselling and psychotherapy with couples, in the UK and beyond. As part of our commitment to professional development you may be seen by a trainee psychotherapist or counsellor working under specialist supervision. • What happens after our Consultation? Following your initial consultation session(s) we will carefully consider the most suitable way forward for you. If this is in our counselling, psychotherapy or psychosexual services we will look for an appropriate appointment for you for regular weekly sessions. There may be a wait until a suitable appointment can be offered, particularly if your times are limited. Once an appointment is offered it will be for the same time each week with the same therapist. It is rarely possible to move the time or day of the session once you start and any sessions you have to cancel or miss need to be paid for at your agreed fee. 2 of 2 84 13.3 Appendix 3: Consultation Report Consultation Report PLEASE WRITE SUCCINCTLY AND DO NOT EXTEND THE BOXES UNLESS ABSOLUTELY NECESSARY. KEEP WITHIN THE WORD COUNT WHICH IS A MAXIMUM LENGTH AND WRITE LESS IF POSSIBLE. 1. Case number Assessment date Assessing clinician 2. Name and contact information Partner A Partner B First name Surname Contact number Email 3. Who attended the assessment session? Partner A Partner B 4. Appearance and manner of the partners. JUST BRIEF FIRST IMPRESSIONS Above all, keep this brief and make your observations tactfully. Write in a way that you yourself would be happy to be written about. Please keep within word count: 100 words MAXIMUM 85 5. Presenting problem Include any differences between the partners about this. Word count: 250 MAXIMUM 6. Brief history of the current relationship You do not need to cover everything. Areas that might be included here: how long have they been together/had problems, their sexual relationship, issues relating to children and parenting; why have they come for help now? Word count: 250 MAXIMUM 7. Children Please detail number and ages of children from current and past relationships Partner A Partner B 86 8. Personal history to include experience of their parents’ relationship, siblings and other family, also previous relationships if relevant. You do not need to cover this exhaustively. Word count: 250 Max Partner A Partner B 9. Genogram Showing current and previous relationships, children age/sex and who living with. 87 10. Please BRIEFLY outline your formulation/understanding of the problems Your understanding will be provisional. Do not feel under pressure to come to an ‘understanding’ prematurely. This section is asking for your views, based on the contact you had with the couple/individual and is inevitably going to be a partial view. Word Count: 200 MAXIMUM 11. How did they respond to your interventions / the things you said? Can you give an example? Note anything significant about transference/counter-transference. Again, please be brief. Word Count: 200 MAXIMUM 12. Risk Factors Are there areas of particular risk or concern? For example, child protection issues, domestic violence, or mental health issues? If you had such concern, did you ask about it? How far were you able to discuss this with them? How did they react? Any concerns must be raised with your supervisor and if necessary a senior clinician, such as Head or Director of Clinical Services. Word Count: 200 MAXIMUM 88 13. Domestic Violence and Abuse Did the couple mention any incidents of domestic violence/ abuse? Yes No If yes, please specify 14. Brief comments on CORE and CSI forms Do not spend much time on this. Just quick impressions, particularly of the CORE forms. Any particular risk factors to pay attention to in terms of their answers on the forms? The CORE items marked ‘r’ for risk must be paid attention to. Is there anything on the CORE forms that was different from your impressions in the session? Word Count: 200 MAXIMUM 15. Other service use If they have had help before or are receiving it currently, please write details of current or past service use, e.g. counselling/psychotherapy; mental health services; solicitor/mediator; Child & Adolescent Mental Health Services CAMHS; social services; drug/ alcohol services. If they are currently under the care of Social Services for example, ask about it – which team, what is the name of their social worker? Partner A Partner B 89 16. Outcome of Assessment Do you want the case to be reviewed before going onto the waiting list? Yes No Have you arranged a second assessment appointment? Yes No Is the decision to proceed with therapy? Yes No 17. Outcome information Case suitable for (please circle one) Student Experienced Newly qualified Experienced student If experienced only, state why Convenient days and times for an appointment Which centre is most convenient for the client Warren Street New Street Counselling Service Psychotherapy Service Psychosexual Service Parenting Together Service. (this service has a £200 fee) Divorce and Separation Consultation Service (DSCS) Referral to another agency (give details) 18. Fee £2 for each £1,000 of income is a rough rule of thumb – as a starting point for discussion Fee paid for assessment session Fee agreed for ongoing sessions (max cap at £180 per session) Please outline how fee was reached If client(s) are paying less than £20 please explain why 90 13.4 Appendix 4: Low Fee Form LESS THAN £45 FOR EVENING SESSION FORM (Evening = after 5.30 pm) CASE NUMBER e.g. 12345 THERAPIST NAME(S) CONSULTATION DATE FEE NEGOTIATED REASON FOR LESS THAN £50 IN THE EVENING DISCUSSED WITH SUPERVISOR DIRECTOR OF CLINICAL SERVICES/ HEAD OF CLINICAL SERVICES AGREE / DO NOT AGREE OUTCOME 91 13.5 Appendix 5: Finance Invoice TCCR Counselling and Psychotherapy Services 70 Warren Street London W1T 5PB 020 7380 1975 Invoice for services Mar 9, 2015 11:45 AM Case ID: 12345 Client(s): Mouse, Minnie Current clinician(s): Current session service: Next session location: TBC 70 Warren Street, London W1T 5PB Previous sessions with amounts outstanding: Date Type Clinicians Service Ccld? Attended Amount due (£) Amount paid (£) Brought forward from previous sessions (£): 00.00 (-ve = balance owed / + ve = balance credit) Todays session: Date Type Clinicians Service Mar 9, 2015 11:30 Regular session AM Ccld? TBC Attended Amount due Amount paid Attended 0.00 0.00 Amount carried forward (£): 00.00 (-ve = balance owed / + ve = balance credit) Amount paid (£): Payment method: Session details: Cash Cheque Session cancelled? Yes No Payment expected? Yes No Is final session? Yes No Credit / debit card BACS Client 1 attended? Spooner, Iain Yes No Client 2 attended? Gouzy, Eglantine Any other comments: 92 Yes No 13.6 Appendix 6: After Consultation Review Request Form After Consultation Review Request Form Clinician Name: Case Number: Date of Consultation(s): I would like this file to be reviewed: Yes No Particular Questions/ Areas of Concern: Discussed in Supervision: Yes No Comments Please remember to fill in the ‘S.17 Outcome Information’ on the Consultation Form regarding the suitability for allocation. 93 13.7 Appendix 7: Clinical Review Summary Clinical Summary Form Clinician Name Couple/Client(s) Initials Case Number (e.g. 12345) Date of Summary Central themes in therapy Any changes since last summary 94 13.8 Appendix 8: Clinician Daily Record TCCR Counselling and Psychotherapy Services 70 Warren Street London W1T 5PB 020 7380 1975 Dec 23, 2013 Clinician Daily Record 23/12/2013 PLEASE COMPLETE THIS FORM ON THE DAY THE SESSIONS TAKE PLACE AND PLACE IN THE RECORD BOX IN THE ADMIN OFFICE Clinician ID Clinician Name 25232013 Minnie Mouse Todays appointments: If you need a new case place complete the NEW CASE NEEDED column. When your case has ended please complete the CASE ENDED column with the date of the last session. Start Room/ Floor ID Clients Client 1 Attended ? Please circle Client 2 Attended ? Please circle Type Status/ Cncld Case ended? Please write date 13:00 Till 13:50 Warren St First, 109 11255 Hermione Granger Ronald Weasley Yes No Yes No Regular Session scheduled 19:00 Till 19:50 Warren St First, 104 11154 Dr Who Clara Oswald Yes No Yes No Regular Session scheduled New Case Needed? Insert Start Date Empty Slots If you need a new case please complete the NEW CASE NEEDED Column. Slots which have a status as reserved are available only due to a regular session cancellation and may well be booked in future Time Room/ Floor CLIN 1 11:00 Till 11:50 WS, First, 109 Minnie Mouse Number of free slots on this day CLIN 2 Type Regular Session 1 Dec 23, 2013 95 Service Counselling Description Status Available New Case Needed? Insert Start Date 13.9 Appendix 9: Complex Case Log Complex Case Log Form Please complete this form and email to Clare Birch (Clinical Services Administration Manager) [email protected] in order for the case to be added to the Complex Case Log. Case Number Clinician Name Date Concern Case Reviewed By Details of concern/ Issue Follow Up Action Agreed Action Implemented? ☐Yes ☐ No 96 13.10 Appendix 10 CORE Form 97 98 13.11 Appendix 11: Couple Satisfaction Index All information will be treated confidentially Please circle Please include only your initials MALE FEMALE _______ _______ Couples Satisfaction Index (CSI-32) 1. Please indicate the degree of happiness, all things considered, of your relationship. Extremely unhappy Fairly unhappy A little unhappy Happy Very happy Extremely happy Perfect 0 1 2 3 4 5 6 Most people have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner for each item on the following list. 2. Amount of time spent together 3. Making Major Decisions 4. Demonstrations of Affection 5. In general, how often do you think things between you and your partner are going well? 6. How often do you wish you hadn’t gotten into this relationship? Always Agree Almost Always Agree Occasionally Disagree Frequently Disagree Almost Always Disagree Always Disagree 5 4 3 2 1 0 5 4 3 2 1 0 5 4 3 2 1 0 All the time Most of the time More often than not Occasionally Rarely Never 5 4 3 2 1 0 0 1 2 3 4 5 99 Completely true 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 completely Almost completely true 4 Almost completely Mostly true 3 Mostly Somewhat true 2 Somewhat A little true 1 A little Not at all true 0 Not at all 7. I still feel a strong connection with my partner 8. If I had to live my life over I would marry (or live with/date) the same person 9. Our relationship is strong 10. I sometimes wonder if there is someone else out there for me 11. My relationship with my partner makes me happy 12. I have a warm and comfortable relationship with my partner 13. I can’t imagine ending e my r lationship with my partner 14. I feel that I can confide in my partner about virtually anything 15. I have had second thoughts about this relationship recently 16. For me, my partner is the perfect romantic partner 17. I really feel like part of a team with my partner 18. I cannot imagine another person making me as happy as my partner does 19. How rewarding is your relationship with your partner? 0 1 2 3 4 5 20. How well does your partner meet your needs? 0 1 2 3 4 5 21. To what extent has your relationship met your original expectations? 0 1 2 3 4 5 22. In general, how satisfied are you with your relationship? 0 1 2 3 4 5 100 Worse than all others (Extremely Bad) 23. How good Is your relationship compared to most? 24. Do you enjoy your partners company? 25. How often do you and your partner have fun together? 0 Better than all others (Extremely Good) 1 2 3 4 5 Never Less than once a month Once or twice a month Once or twice a week Once a day 0 1 2 3 4 5 0 1 2 3 4 5 More often For each of the following items, select the answer that best describes how you feel about your relationship. Base your responses on your first impressions and immediate feelings about the item. 26. INTERESTING 5 4 3 2 1 0 BORING 27. BAD 0 1 2 3 4 5 GOOD 28. FULL 5 4 3 2 1 0 EMPTY 29. LONELY 0 1 2 3 4 5 FRIENDLY 30. STURDY 5 4 3 2 1 0 FRAGILE 31. DISCOURAGING 0 1 2 3 4 5 HOPEFUL 32. ENJOYABLE 5 4 3 2 1 0 MISERABLE 101 13.12 Appendix 12: Experience of Service Questionnaire 102 103 13.13 Appendix 13: Risk Identified Form Risk Identified This client or couple has scored on a risk factor on either the intake forms or regular follow up forms. Please consider this when making clinical decisions. Case ID Date Forms (intake / 3 month etc) Forms processed by Client 1 ID Client 2 ID Gender Gender Risk Identified (Y / N) Risk Identified (Y / N) Clinician Emailed by: 104 13.14 Appendix 14: Risk Identified Notification Email From: "Mandip Matharu" <[email protected]> Subject: Risk Identified Date: 9 March 2015 13:01:32 GMT To: "Clare Birch" <[email protected]> Dear It is standard practice to let clinicians know if any risk was identified on the CORE forms. The male/female client from your case XXXX (initials) has scored on a risk factor (/more than one risk factor) on her/his most recent set of CORE forms. The forms have been processed and will be in their file shortly. Mandip Matharu | Receptionist/ Database Co-ordinator 105 13.15 Appendix 15: Disability Identified Notification Email From: "Mandip Matharu" <[email protected]> Subject: Disability/Illness Identified Date: 9 March 2015 13:01:06 GMT To: "Clare Birch" <[email protected]> Dear It is standard practice to let clinicians know of any disability/illness identified on the Equal Opportunities forms. The male/female client from your case xxxx (xx) has indicated XXXX. Please be aware Equal Opportunities forms will not be provided in their file. Kind regards, Mandip Mandip Matharu | Receptionist/Database Co-ordinator 106 13.16 Appendix 16: Covering Letter about Measures Dear Client, Re: Outcome monitoring questionnaires Enclosed are questionnaires that we ask you to complete at regular intervals while you are receiving services from TCCR. We would be very grateful if you could return them to the receptionist in the envelope provided when you attend your next appointment. Your clinician will also see the forms that you return. You will notice that they are the same forms you filled in before your consultation appointment with us. The reason for asking you to fill them in again is so that we can see how we are helping you. You can talk with your therapist about how you have filled out the forms, if you would like. Your therapist may bring them up with you, too. We use the forms anonymously to see how we are doing over time with different kinds of individuals and couples, and to compare our progress with other psychotherapy services. We know that some of the questions can feel difficult but your answers are valuable. If you have any questions about these forms please do talk to your clinician. We appreciate you taking the time to do this. Yours sincerely, Limor Abramov Head of Clinical Services, Quality Assurance 107 13.17 Appendix 17: Fly Sheet for Outcome Monitoring Case ID: Interval To be completed by reception Date Due to Date Be Given Inserted Out Clinician Name: To be completed by the clinician Date Given Out Reminder Date Issued Returned Clinician Initials 6 Weeks 3 Months 6 Months 9 Months 12 Mnths 18 Mnths 24 Mnths 30 Mnths End of Session Questionnaires (If Sent By Admin only) End of Session Questionnaires To be completed by clinician (If planned Ending) Date given Date Due to be given out out Clinician Initials If sent out by Admin- Administrator to Complete Date Sent to Administrator Reminder Clients Initials Email Sent 108 Date Returned Date Returned 13.18 Appendix 18: Closing Report Closing report Case number Clinician Service Date of last session Name of clients Partner A initials: Partner B initials: Client id First name Surname Reasons for ending therapy (Please add details and note any differences in couple’s and therapist(s) view) Unplanned due to crisis Unplanned due to loss of contact Client did not wish to continue Other unplanned Planned from the outset Agreed during Agreed at end Other planned Client decided to go OWL 109 Number of sessions Case terminated by (Please add details and note any differences in couple’s and therapist(s) view) Clinician Client(s) Mutual Referral Factual process of therapy (Including date when therapy started and ended; frequency of sessions; whether seen as a couple or single; any significant breaks in therapy) Significant life events or changes in life situation during therapy (Including any changes in living situation) Emotional state of the partners (Note how they relate to each other at the end of therapy and any changes from before) 110 Domestic Violence / Abuse Did the couple mention any incidents of domestic violence/ abuse? If yes, please specify Yes No Were there any changes or improvements over the course of therapy? How did the couple/individual relate to the therapist(s) over the course of therapy? (Note any changes in the transference and countertransference) Assessment of couple interaction at the end of therapy (Note changes in the marital fit, shared defence, shared phantasy and corresponding intrapsychic change? What has not changed?) 111 External correspondence (Give details where appropriate) Letter to GP Letter/report to referrer End of session questionnaires Given to client/couple in penultimate session Yes Date Issued Posted to client/couple after sessions ended Yes Date Issued If it is not appropriate for the End of Session Questionnaires to be issued to the client please state the reason: 112 13.19 Appendix 19: Annual Fee Uplift Form Annual Fee Uplift Form (Cases having regular sessions for 6 months + starting before 1st October 2014) CLINICIAN Name SUPERVISOR Name Case ID Number e.g. 12645 Date Regular Sessions Started CURRENT FEE (as at March 2014) RENEGOTIATED FEE (from April 2014) Signed off by Supervisor Please return this form to Clare Birch 113 Finance Notified (please tick to confirm) 13.20 Appendix 20: Client Invoice Form 114 13.21 Appendix 21: Tracer Card Clinical File Audit Dear Clinician Case number has been selected at random to be audited as part of our clinical audit. The file will be returned to your slot once the audit has been completed. If you need access to your file please contact Naomi Mwamba (Research Assistant 3rd Floor). Kind Regards Andrew Balfour Director of Clinical Services 115 13.22 Appendix 22: TCCR USB Memory Stick Declaration USB Memory Stick Agreement You have been issued with a TCCR encrypted memory stick. It is a requirement of working within the clinical service that you comply with the organisation’s confidentiality policies and procedures. It is important that you are aware of, and adhere to, TCCR’s confidentiality policies. Please see attached sheet for a summary of the key requirements- the version of the policies are contained within the staff handbook. By signing this agreement you are confirming that: 1. You will only save clinical documents on the TCCR issued encrypted memory stick. 2. Clinical documents on all other memory sticks and personal devices have been deleted. 3. You will comply with all confidentiality policies and you understand that a breach of these policies may result in disciplinary action. 4. You will make available the memory stick device if requested for audit by TCCR. Print full name Signature Date ----------------------------------------------------------------------------------------------------------------Receipt for payment of £20 deposit for Encrypted USB Memory Stick Received By (signed by TCCR staff member) NAME: Signature: 116 Instructions for Use of Memory Stick Corsair USB Stick How to unlock your Corsair USB memory stick 1. Press and release the Key button (located directly above 0|1 ) 2. The padlocks directly above the key will start to flash, red on the left and green on the right 3. Enter your PIN [To select the number on the left e.g. 0, press the 0|1 button once, to select the number on the right e.g. 1, press the 0|1 button twice.] 4. Press and release the Key button 5. The padlock button on the right will flash green and is now unlocked 6. Insert your memory stick into a USB port The memory stick will lock automatically as soon as you remove it from the USB port. 117 TCCR Encrypted USB Memory Stick Reminder of Policies and Procedures (September 2014) We wish to remind all clinicians of our current policies on confidentiality and the handling of clinical information. Please re-read the policies in full (see staff handbook). Below are some of the key points: Clinical information and client data is absolutely confidential Confidential information should never be disclosed to unauthorised third parties and you should only work on TCCR clinical work in a private setting or on TCCR premises. No names or contact information should be contained in any clinical write ups For Clinical Session Notes, Six Monthly Summary, Closing Reports, Consultation Reports, emails or any other clinical documents, only use client initials, first names or case numbers to identify the clients. No contact information should be contained. No names or contact information should be contained in any emails When sending a draft email to appointments use only case numbers and initials to identify which case the message should be sent to. Client contact information on Consultation Reports should be written in by hand on site at TCCR at the time you are handing in your report. Under no circumstances should this report be saved anywhere with this contact information included. Client names should not be put on any invoices or claim forms for clinical work. Case numbers only should be used. A new version of the clinical claim form has been drafted which removes any reference to names. Copies are available in the Lobby and Common Room- please destroy any previous versions of this document which you may have. All Documents Containing Clinical Information Must Be Password Protected Word: to password protect a word document click on the ‘File’ tab on the top tool bar. Select ‘Info’ from the menu then select ‘protect document’ icon to the left of ‘Permissions’. A further menu will open and you should select ‘Encrypt with password’. Enter the password carefully (you will be asked to enter it twice). If you are emailing the document never send the password with the document. You should always send the password in a separate email, text or call the recipient with the password. MAC Users: If you have Word installed on your MAC you should write up documents using Word and use the instructions above to password protect. Client Files must never be removed from the building If you need to transfer a documents or files between our Warren Street and New Street sites this should only be done via the TCCR clinical courier system. 118 Email Accounts All non TCCR email addresses must be private If you are using a non TCCR email account for clinical correspondence you must ensure it is a private email account which is not accessible by anyone else including family members. The account must be password protected. Personal devices used to access clinical emails should be password protected If emails are accessed on personal devices (including smart phones) the device itself should be password protected. This is in addition to the requirements above regarding no confidential content being contained in emails. Saving Clinical Documents and TCCR Issued USB Memory Sticks Any clinical documents should only be saved to your TCCR issued USB stick. TCCR clinical related emails or documents should never be saved to Dropbox or any personal devises such as home PCs or laptops. Any clinical information stored anywhere other than the TCCR issued USB memory stick (e.g. other memory sticks or devises) must be wiped. Once you have completed a document and it has been added to the file as finished you must delete the document from your memory stick. Only documents you are currently working on should be saved to the memory stick The encrypted USB Memory sticks are in addition to, and do not replace the requirements above on client names and contact information. 119
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