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Ethics In A Digital Age

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OBJECTIVES
To articulate your philosophy of practice
Review Duty to Warn, Duty to Protect & Privilege Communication
Explore Ethics in Todays world-Opioid Crisis - Me Too- Legalization of Marijuana - Medication Assisted Treatment
Explain, Describe & Differentiate Digital Policies and Ethics for Licensed Clinicians
View Social Media & Advertising in Digital Age
Evaluate Tele Psychology
Examine The Emergence of Open Notes as an Ethical Issue

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Ethics In A Digital Age

  1. 1. Ethics in a Digital Age Louise StangerEd.D, LCSW, CDWF
  2. 2. Meet Dr. Louise Clinician Author Educator Interventionist Family Specialist
  3. 3. Cell Phones How many of you text? How many of you text clients? “nonsecure transmission” Record that you texted 24 hour availability
  4. 4. Objectives To articulate your philosophy of practice Review Duty to Warn, Duty to Protect & Privilege Communication Explore Ethics in Todays world-Opioid Crisis - Me Too- Legalization of Marijuana - Medication Assisted Treatment
  5. 5. Objectives Explain, Describe & Differentiate Digital Policies and Ethics for Licensed Clinicians View Social Media & Advertising in Digital Age Evaluate Tele Psychology Examine The Emergence of Open Notes as an Ethical Issue
  6. 6. Ethics
  7. 7. Top Clinical Concerns
  8. 8. What is your Philosophy of Treatment ? Take a few minutes and write down 3 or 4 (words) sentences that describes your philosophy of treatment
  9. 9. You are in the Possibility Business
  10. 10. What are Ethics? Beliefs an individual or group makes about what constitutes proper behavior Standard of Conduct
  11. 11. Ethics are Not Laws Do Not Confuse Ethics With Morality Ethics are Not Religion
  12. 12. Types of Ethics Mandatory Ethics Must do or Must not do Actions that are safe and legal Aspirational Ethics More the meeting basic code
  13. 13. Principal or Virtue Ethics Is what I am doing best for client Character traits Situation Unethical? Methods or Obligations
  14. 14. Ethical Codes Ethics are not absolute in all situations Ethical Codes are not Cookbooks Consider the code within professional organizations Each client is unique Each situation is different requiring unique solutions.
  15. 15. Purpose of Ethical Codes Protect the welfare of clients Protect the public Guide professionals in Daily work Provide Guidance
  16. 16. Limitations Some issues cant be handled relying on ethical codes by themselves Some lack clarity/precision, blurred lines Simply learning codes and guidelines wont always lead to ethical practice Conflicts can e within codes and among various organizations Members may hold state and national certifications and licensees which may all not be uniform.
  17. 17. Codes need to be reactive not proactive Personal Values may conflict with a standard ethic code Codes must be understood within a cultural frame Codes may vary with state laws and regulations Not all members of within a professorial organization will agree with all elements of a code
  18. 18. Steps for Addressing and Reporting unethical behaviors Obligation to deal with unethical conduct Talk to person, intervene if possible Try to resolve at lower, informal level Seek consultation If egregious act , reporting is necessary If you see clients that are professionals, encourage them to self report
  19. 19. Reporting Obligations We are Gatekeepers Don’t Assume someone else will do it Responsibility to confront recognized unethical behavior Legal Responsibilities Ignoring ethical misconduct is an ethical violation Document, Consult, Obtain Supervision
  20. 20. What are the 3 most difficult topics for you to be objective about with a client List at least 1 type of client you find challenging? Think of a case an how did you handle that? What personal value did you struggle with ? Did you talk with a supervisor ? Do you seek out professional therapy?
  21. 21. What’s our Job? To star on a TV Show, Dr Phil, The Doctors Etc To help client adopt better values To indoctrinate clients To teach proper behavior To prescribe happiness To be a guru and share wisdom To preach, pontificate , persuade, lecture ?
  22. 22. Where do you Stand on ?
  23. 23. Your Client asks you To let the TV Camera Into Your Office.
  24. 24. Questions If she wants her sessions to be filmed is that in alignment with my values? This would generate new business for my practice and also put me under scrutiny. What kind of guard rails do I need to put in place to protect me, my business and my families? Would the MFT, LPC, Social work, Psychology Board allow our sessions not only to be filmed but to be shown on TV? Would I be able to edit? What type of oversight might I have? What type of disclosure would I have to sign/ Would I need an agent?
  25. 25. Ethical Principles Respect for one another Universality Utility - the duty to provide the greatest good or least harm to the greatest number of people Ordering of priorities
  26. 26. Principles of Ethics Autonomy - freedom of choice Non-malfeasance - To Cause No Harm Gratitude Beneficence - To Do Good Justice - Treat all Fairly Fidelity - honoring Commitments Reparation - duty to make up for wrongs
  27. 27. Competence Integrity Importance Of Human Relationships Dignity of Individual Social Justice Service VALUES
  28. 28. Ethical Issues Individual Group Organizational Societal
  29. 29. Teen Line-Michele Carlson MPH
  30. 30. How do Ethical Problems Occur Human error Clients misreport Inexperience Ignorance Unpredictable / Unforeseen situations Inadequate Agency policies Ethics in conflict with law
  31. 31. Ethical Considerations Fiduciary Relationships with Provider Call Centers Pay per Click Truth In Advertising Gifts and Kickbacks Confidentiality
  32. 32. Top Issues Dual Relationships Friendships / Counselor-Client Sexual Relationships Professional - Client and colleague are professionals Business - Counselor and client are business partners or have an employer relationship Communal (both belong to same community: AA, ALANON, NA, etc.)
  33. 33. Confidentiality and Duty to Warn Hallmark of therapeutic relationships Record Keeping Gossiping/Slander Photos Intentional infliction of emotional distress Tarasoff Rule With minors and with groups
  34. 34. Competence How do you achieve and maintain? Cultural Is it ok to practice outside of cultural competence?
  35. 35. More Issues Patient deaths Non-profits set up to run call centers Ownership - should labs own treatment centers Insurance companies dictate treatment Public's distrust of the behavioral healthcare industry Lack of generalized training and standards
  36. 36. Need Clients
  37. 37. Ethical Responsibilities Micro-Individual Level To Clients To Colleagues To Practice Settings To Professional Affiliations To Broader Society
  38. 38. The Dilemma To Tell the Truth Herein lies the dilemma between self, IP, Agency and Outside World.
  39. 39. “Rated the Number One Rehab in the World”
  40. 40. “The Two Week Detox, Treatment & Golf Plan”
  41. 41. Promise More Then You can Deliver
  42. 42. Using your Internet Site & Name
  43. 43. What is yours?
  44. 44. How Many of Your Clients
  45. 45. Guidelines
  46. 46. What’s good about social media Provide services to folks who are remote, have disabilities Engage in professional networking Obtain continuing education Obtain support-self support groups Collaborating
  47. 47. Social Media Provide Therapy Access to records Means of maintaining communication
  48. 48. Who are our Clients ? Digital Natives Digital Immigrants Digital Fugitives
  49. 49. Confidentiality A Clients Right to Privacy A clinician may not disclose information without a clients consent- Identify of client , content of communications, professional opinions about the client and materials from record
  50. 50. Confidentiality etc. Patient or client privacy Confidentiality Matters of Informed Consent Solicitation of Clients Conflicts of Interest
  51. 51. Faxing
  52. 52. Faxing Cover sheets- contain notice of prohibition of disclosure Where is the fax? Where is the other fax? Who is receiving fax?
  53. 53. Duty to Warn Threatens on the internet
  54. 54. Duty To Warn Tarasoff Ruling 1974 Does client pose a serious threat to an other ? The ethical obligation of confidentiality comes in conflict with duty to warn and duty to protect
  55. 55. Duty to Protect With Homicidal or Suicidal Clients ? HIV and AIDS Domestic Violence Client Cutting Themselves Geriatric patient ability to care for herself
  56. 56. Decision Making Duty to Warn Duty To Protect Gather relevant Data Evaluate Dangerousness Determine Course Distinguish between making a threat and posing a threat
  57. 57. Privileged Communication Privileged Communication is guaranteed by all the states and federal statue 501. Based on Court Case 1995 Jaffee vs,. Redmond
  58. 58. How many of you? Have a website? Facebook? Instagram? Twitter/ Linked In? Snap Chat? Messages Consult via Phone , Skype, Zoom etc
  59. 59. Professionals Using Social Media Addiction counselors Interventionists Nurses Marriage and Family Counselors Physicians- Dentists Pilots Psychologists Social Workers Teachers
  60. 60. How many of you have ? Silly photos Perhaps at a party drinking Doing something dangerous Calling Out Someone Not Checked your privacy settings
  61. 61. 88% of 18-29 years olds use facebook 84% of 30-49 year olds use Facebook 72 of 50-64 year old Facebook 62%of 65 year old use Facebook
  62. 62. Demographics • 82% of adults with some college experience use Facebook. • 79% of adults who graduated college use Facebook. • 77% of adults with a high school diploma or less use Facebook. Education • 84% of adults who make less than $30,000 use Facebook. • 80% of adults who make between $30,000–$49,999 use Facebook. • 75% of adults who make over $75,000 use Facebook. • 77% of adults who make between $50,000–$74,999 use Facebook. Income
  63. 63. Instagram • 59% of 18–29 year olds use Instagram. • 33% of 30–49 year olds use Instagram. • 18% of 50–64 year olds use Instagram. • 8% of people 65+ use Instagram. Age • 38% of online women use Instagram. • 28% of online men use Instagram. Gender • 39% of adults living in urban areas use Instagram. • 31% of adults living in rural areas use Instagram. • 28% of adults living in suburban areas use Instagram. Live 33% of adults who graduated college 37% of adults with some college experience 27% of adults with a high school diploma or less Education 38% of adults who make less than $30,000 37% of adults who make more than $75,000 32% of adults who make $30,000–$49,999 32% of adults who make $49,999–$74,999 Income
  64. 64. All Social Media 79% useFacebook 32%use Instagram 31% use Pinterest 295 use LinkedIn 29% use messaging apps 24% use auto-delete app
  65. 65. Daily User Social Media Demographics 76% Facebook 51% Instagram 42% Twitter 25% Pinterest 18% Linked in
  66. 66. Global Issues Should every home have Narcan? Should cannabis be used for opiate withdrawal? How should cannabis be marketed and regulated? Advertising and regulating Drug trafficking - human trafficking
  67. 67. Top Macro Concerns Patient Brokering - Paying for Referrals Improper Billing - UA Billings Incorrect Billing with Insurance and Private Pay (Waving Deductibles) Unlawful Kickbacks Deployment of Staff - Having Non-Credentialed Staff Facilitate Clinical Events
  68. 68. More Issues Patient deaths Non-profits set up to run call centers Ownership - should labs own treatment centers Insurance companies dictate treatment Public's distrust of the behavioral healthcare industry Lack of generalized training and standards
  69. 69. Google Analytics and Other Issues Buying ad words Fake positive reviews Buying competition's keywords Kickbacks - reciprocation Stealing websites - called redirecting
  70. 70. McDonald, Sohn & Ellis 2010 We must become e-professionals
  71. 71. E-mailing Do you have written permission? Recorded in File Policies- Availability, consent emergencies Informed Consent Discoverable in court
  72. 72. Emailing Encrypt De-identify Email has no expiration date and can be
  73. 73. Case Study Technology Breach of Confidentiality A therapist updated files while on a flight. As she completed a treatment summary she was directed to turn off all electronic equipment . She saved it to a hard drive and backed it up on removable disc She left the disc on the airplane The use of encryption would of prevented this
  74. 74. Case Study Where did that email go? Ever hit the send button and realize that it was confidential material that went the wrong place! You have a consent form to fax to X , its all prepared , you turn your head and OHNO
  75. 75. Mailings If a treatment center send out a mailing that highlights their alumni program and lists names of alumni If we take a photo after this course and I send it out in a mailing…
  76. 76. E-Etiquette No inappropriate email addresses Formal Check spell check spell check spell check Read and reread emails to guarantee tine and message
  77. 77. Managing Electronic Files Firewalls Encryption Complex Passwords privacy Screens Protect physical security of portable devices zUpdate Virus Protection Remove all information when disposing of files.
  78. 78. Boundaries -Dual Relationships No physical contact with Client No Contact outside of consulting room Maintain objectivity and neutrality and avoid excessive worrying Seek Supervision Counter Transference Enactment- Edgar Levenson
  79. 79. Boundary Crossing Vs. Boundary Violation
  80. 80. Boundary Crossing Change in role Most likely to benefit the client One time event - Unintentional Disclosure Discussed with client setting healthy boundaries Can be therapeutic BUT -can lead to BLURRED LINES
  81. 81. A Slippery Slope Attempt to blend roles that do not mix May be harmful to client Multiple Roles gets Confusing
  82. 82. Social Networking Problems Self -Disclosure! Dual Relationships! We are not our clients friends! Confidentiality
  83. 83. Questions to address Do you know the difference between Facebook Profile and FaceBook Page? ( 2014 ACA tells to keep Facebook Page Separate) Do you use Privacy Controls to Control Access? What can a Client view on therapist profile? What did the client request? Who is the client?
  84. 84. Boundary Violation Exploitation of client to some extent Can do harm to client Repeated on numerous occasions
  85. 85. Checking Social Media Profiles.. A patients or client is admitted too a Psychiatric ward or ER and indicates desire for self harm , up to and including suicide or or harm someone else. What would you do?
  86. 86. Reach out On Facebook A friend reaches out to you on Facebook and says they want to harm themselves. You are a licensed clinician what do you do?
  87. 87. The question that must be answered How might the therapists response to a client’s Facebook friend request affect treatment and the therapist alliance
  88. 88. What is the nature of the therapy relationship ? Where is therapy taking place? What does friend mean to client too therapist? Does accepting a friends Request automatically How might the therapist response to a friend req
  89. 89. Checking Social Media Files Ghosting- looking up the address where a person lives Following their Twitter feed Checking out Linked in and commenting Blogging about client Blogging about unethical practices and calling out other practitioners or centers
  90. 90. What would you do? A colleague posts and vents about her supervisor on social media? An interventionist says “off to save other life”? A treatment center posts accepting new clients? A clinician indicates they are a “international thought leader”!
  91. 91. George / Sally is a professional Counselor who works with clients with co-occurring disorders He/ She makes a decision to join Facebook so he can search his clients and see what they are doing. Issues- Client right to privacy Client-Therapist Relationship Ghosting or Haunting Clients
  92. 92. More What Would You do? People rant on Facebook about Ethics People Develop websites on Ethics Your client
  93. 93. Dual Relationships Case Study A Therapist and an ex client decided they would become friends because the therapeutic relationship was quite harmonious. They became friends on Facebook, Linked in and Instagram. And Then they started Dating ….
  94. 94. Transference
  95. 95. Countertransference
  96. 96. Prickly Situations Love, lust , curiosity, envy, Competition, distaste and even hatred Relationships
  97. 97. Blogging Post only if clients gave written permission Be prepared for reader response Be Consistent Refrain from liking groups and causes on Facebook
  98. 98. Clients subscribing to Blog Sites “I do not accept friend or contact requests from current or former clients on any social networking site” I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this we can meet and discuss ?
  99. 99. Case Study Blogging for Suicide Strategy Set goal for Blog Post Determine Audience Address specific Actions Measure Blog post results
  100. 100. Writing Safe Content Avoid overstating issue -don’t use words like “suicide epidemic or skyrocketing Avoid words like “successful”, unsuccessful
  101. 101. Writing Safe Content Avoid using phrases that overstate problem -“Epidemic or Skyrocketing” Do not depict or use images showing methods of suicide, self harm or violence Avoid words like “successful, unsuccessful, failed attempt,” instead use “died by suicide, completed or “killed himself or herself” Include prevention hotlines, warning signs and other prevention focused information Do not include personal details of the person who died by suicide. Use the persons story to talk about prevention, coping seeking help
  102. 102. Personal Safety and Privacy Only disclose personal details you are comfortable with Before publishing disclose personal details privately to those it may impact negatively Be Sensitive Be Respectful
  103. 103. Monitoring Your Blog Comments Check comment section regularly Do not ignore suicidal threats Take action against reuse, derogatory or discriminatory comments Avoid arguing in comment section Steer conversation back on topic Choose a comment thread that works best for you
  104. 104. Talking With Media Personal Story _be sure story is appropriate for wide audience’ Refer Journalist to speak with an expert and if you are the expert do not confuse your story with expert facts If you don’t know an answer say so
  105. 105. Advertising Are you depressed/ Stressed Out/ We can Help You. Call We can “Cure “ Addiction Dr. X- Your one-stop station for mental health ‘We offer evidenced based treatment If Bill W were alive he would sign u for counseling with me.
  106. 106. Promises Health and Wellness Personal Power and Creative Change -The Karma Institute In a weekend you can become ………
  107. 107. Federal Trade Commission by 2018 , 50% of all smartphone users will be using mobile health phone applications improve and facilitate patient care Focus on apps to consumers - Head space, LacMac Provides nursing mothers , diabetics etc. https://www.fda.gov/MedicalDevices/DigitalHealt h/MobileMedicalApplications/default.htm
  108. 108. The FDA Provide patients with simple tools to organize and track health information provide easy access to information related to health conditions and treatment’ Help patients document potential medical conditions’ Automate simple health care tasks Enable Patients to interact with Personal Health Records or Electronic Health Records Does not apply to Electronic Health Records
  109. 109. In Your Face Solicitation Sally G bragged to her colleague that she attracted many of her clients by frequenting upscale bars at night who seemed depression and gave out her card I go to Soul Cycle and hand out cards
  110. 110. Acceptable advertising “You are not alone we are here to help” Does not generate fear Offers encouragement to seek help for emotional problems “Depression & anxiety are treatable. Chronic Pain & substance abuse is treatable Heres some ways to help you
  111. 111. APA Guidelines Must avoid making false or deceptive statements related to one’s practice ,research or credentials Maintain the integrity of statements made by other on our behalf Do not compensate the media for publicity about our practice news items When we offer public advice must cite scientific basis for claims Do not solicit testimonials from clients who are vulnerable to undue influence Do not personally or through agents, attempt uninvited in-person solicitation of business from actual or potential clients which make them vulnerable to undue influence List degrees correctly
  112. 112. Testimonials She is an “international world class speaker” This is “World Class Addiction and Mental Health Treatment Center”
  113. 113. Telepsychology Guidelines and Questions
  114. 114. Definition The Provision of psychological services using telecommunication technologies Telephone, mobile devices, interactive technologies, videoconferencing, email , chat, text, internet( send help websites, blogs, and social media) Can be use to augment services or provide direct services , eg email for scheduling, telephone for direct services Skyping- Face Time
  115. 115. Offering Access Increased access for folks with physical, medical and/or mobility disabilities Increased access to areas that have little mental health services Flexible scheduling Access to therapy in native languages (American sign)
  116. 116. Terms Synchronous Service- Communication in real time between a Professional and a consumer Asynchronous Service- Communication in a time delayed Manner between a professional and a consumer
  117. 117. Considerations Legal Requirements Ethical standards Telecommunication technologies Interagency polices External constraints
  118. 118. Mobile Aps
  119. 119. Digital Aps
  120. 120. 8 Step Model For Ethical Decision Making (Cory, Cory, Callahan) 1. Identify the Problem or Issue Clinical Legal System - Policies, etc. Cultural Personal
  121. 121. Steps 2 - 4 Identify the potential issues Look at relevant codes of ethics for general guidance Consider applicable laws and regulations and determine how they may have bearing on ethical dilemma
  122. 122. Steps 5 - 7 Seek consultation from more then one source to gain multiple perspectives to the dilemma Brainstorm various courses of Action List pros and cons of potential action
  123. 123. Step 8
  124. 124. What are you going to do?
  125. 125. Additional Thoughts Corporate Responsibilities Rene Popovitz JD 1.Written Policies and Procedures High Level Responsibility Effective Training and Communication Response and Correction Discipline and Enforce meant Auditing and Monitoring
  126. 126. All Staff- Clinical Staff-Leadership Ethics applies to everyone
  127. 127. All Staff Code of Ethics Care and Respect Confidentiality Recovery Environment Professionalism Integrity Accountability Corporate Compliance
  128. 128. Clinical Code of Ethics Therapeutic Relationship Quality Evidenced Based Practices Compliance and Licensing Standards Truthful billing and Documentation
  129. 129. Leadership Code of Ethics Ethical Business Practices Responsible Technology Marketing & Community Relations Financial Accountability Quality and Outcomes Monitoring Talent Management, Innovation and inspiration Risk Management , Safety & Security
  130. 130. Employee Reporting Mechanisms Responsibility to report illegal or unethical conduct External or internal hotline Reports follow existing supervision lines Prompt responses to reports is essential No retaliation / disciple for deliberate false accusations Efforts to preserve Confidentiality
  131. 131. Categories Of Decisions What is Moral What is Ethical What is Legal What is Professional Appropriate
  132. 132. White & Popovits 2001 One of the greatest threats to our field comes not from changing drug trend, external regulations or changing methods of reimbursement but from our own failure to clearly define work and ourselves
  133. 133. Zones of Ethical Vulnerability Conduct related to business, marketing & referral practices Personal Conduct Professional Conduct Conduct in professional peer relationships Conduct in relationships with service consumers Conduct related to public safety Conduct related to Technology Conduct related to managing care and population health
  134. 134. Business Practices Most troublesome areas Financial Improprieties Conflicts of interest Unethical Marketing Practices Referral Fees and Renumeration
  135. 135. Transparency Ownership Disclosures Coordination between state & local Coordination between government and private sector insurance Data Collection & sharing Integration of Data Sources
  136. 136. Resources Zur, O. PHD. ,The National Psychologist -Social Networking How Should Psychologists Respond To Online Requests. Our Institute http://www.zurinstitute.com/social_networking.html “Sorry Your Therapist Can’t be your Friend”-American Psychoanalytic Society Sept. 14, 2017https://www.psychologytoday.com/us/blog/psychoanalysis -unplugged/201709/sorry-your-therapist-can-t-be-your-friend Code of Ethics American Association for Marriage and family Therapy http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Co de_of_Ethics.aspx
  137. 137. Resources Patterson, Francis. PHD, LADAC II, MAC -Not The Usual Ethics Training : Navigating Difficult and Challenging Situations Journal of Social Work Values and Ethics, Spring, 2014 Vol.11 page 1 Zur, O. To Google or Not Google our clients/ When psychotherapist and other mental health professionals search their clients on the web. Independent Practitioner 30, 144-148
  138. 138. Resources Katheryn Chernak PHD Social Media and Social Work : A Question of Ethics https://socialworklicensure.org/articles/social- media-social-work Telepsychology with Persons with Disabilities www.apa.org/pi/disability/resources/publications/telepsycho
  139. 139. Resources Robb, Matthew. “Pause Before Posting: Using Social Media Responsibly.”Social Work Today. Jam-Feb.2011 Blogging for Suicide. orghttps://www.bloggingonsuicide.org Ethical Decision- Making in Social Work Practice, Sept. 2015, NLASW Professional Issues Committee
  140. 140. Resources digital-interventions-for-reducing-alcohol-consumption-do-t ining The Virtues of Compliance- Renee Popovits , Sept 1,

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