Ethics in Practice: Mandated Reporting, Boundaries, and Decision-making


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Ethics in Practice: Mandated Reporting, Boundaries, and Decision-making

  1. 1. John D. Gavazzi, PsyD ABPP Baltimore County Department of Health June 2014 Ethics in Practice: Mandated Reporting, Professional Boundaries, and Ethical Decision- making
  2. 2.  List the differences between ethical, legal, and risk management concerns  Outline a model for integrating professional ethics with personal values  Use one decision-making model to work through an ethical vignette
  3. 3. The process is often ambiguous
  4. 4. 1. Move away from the “ethical” versus “unethical” decision. 2. In some ethical decisions, there is not “right” or “correct” answer for everyone. 3. Most clinicians make ethical decisions on a daily basis
  5. 5. Having an ethics code or attending lectures on ethics codes are among the least effective ways to ensure ethical behavior.
  6. 6. People should not act on principle (standing on principle can be an unprincipled stand)
  7. 7. Rational Social Worker: Know the Code!! Social Worker Patient Learn the rules Apply the rules Outcomes will follow
  8. 8. PatientSocial Worker Learn the rules Apply the rules Outcomes will follow Understand patient dynamics Understand the relationship Know the Code + Know your patient
  9. 9.  Clinical Decision-making  Risk management  Legal Decision-making  Ethical Decision-making ◦ Professional Ethics ◦ Personal Ethics, Values, or Morality
  10. 10.  What is the best clinical intervention for this patient in this situation?  Am I conceptualizing this patient correctly?  My patient continues to struggle after eight sessions. What should I do?
  11. 11.  How do I work with a patient to minimize risk or liability?  Avoid types of work that have high liability risks, such as custody evaluations or clinical complex patients.  Do I have essential paperwork signed? Informed Consent or practice policies current
  12. 12.  Always have a suicidal patient sign a “no suicide” contract  Never touch a patient  Always remain at a professional distance emotionally and socially  Boundary crossings vs. boundary violations
  13. 13.  Am I compliant with state laws and regulations?  Is my practice HIPAA compliant?  Am I aware of relevant case law in my state?  Questions are usually asked of an attorney
  14. 14. Professional Ethics  Do I follow the NASW’s Code of Conduct?  Am I performing at the minimum or reaching for the aspirational ceiling?  Is my behavior linked to a foundational principle?
  15. 15. Personal values, ethics, and morality  Is what I am doing consistent with my values?  What is my emotional response to the patient, lifestyle, or behavioral issue?
  16. 16. 1. Religion/Family of Origin 2. Education: College and CE 3. Personal Education: Reading and Experience 4. Honest self-reflection
  17. 17.  How did it develop?  How often do you use it to reflect on professional life?  How often do you use it to reflect on personal life?  How do you integrate morals into ethics?
  18. 18.  Do you use it “before the fact”?  Is it intuitive and unconscious?  Is it more cognitive?  Is it written down?
  19. 19.  Is it acceptance of another person’s code in full?  If yes, why?  If not, why?
  20. 20.  Do you use it “after the fact”?  Fundamental Attribution Error  Actor-Observer Bias  Motivated Moral Reasoning
  21. 21.  Looking at how well a social worker integrates his/her values and behaviors into the ethical culture of social workers  Social Work has a set of normative principles and behaviors related to ethical behavior and appropriate conduct
  22. 22.  One way of remaining a life-long learner  Provides another way to discuss ethical behaviors and decisions
  23. 23. A process to change the cultural behavior of an individual through contact with another culture. The process of acculturation occurs when there is an adaptation into an organization or society.
  24. 24.  An outgrowth of positive ethics that integrates personal ethics and professional obligations.  Social Work has a system of shared and distinctive norms, beliefs, and traditions.  This set of beliefs is reflected in the ethics code.
  25. 25.  Can be a complex process  Some parts of a social worker’s practice and lifestyle may be easily acculturated while others not  Process that will likely continue throughout the education or career as a social worker
  26. 26. Identification with personal value system (higher vs. lower) Identification with value system of psychology (higher vs. lower)
  27. 27. Acculturation Model of ethical development Integration Separation Assimilation Marginalization Higher on Professional Ethics Higher on Personal Ethics Lower on Personal Ethics Lower on Professional Ethics
  28. 28. Matrix: Lower on professional ethics Lower on personal ethics Risks: *Greatest risk of harm *Lack appreciation for ethics *Motivated by self-interest *Less concern for patients
  29. 29. Matrix: Higher on professional ethics Lower on personal ethics Risks: Developing an overly legalistic stance Rigidly conforming to certain rules while missing broader issues
  30. 30. Matrix: Lower on professional ethics Higher on personal ethics Risks: Compassion overrides good professional judgment Fail to recognize the unique role of social workers
  31. 31. Matrix: Higher on professional ethics Higher on personal ethics Reward: Implement values in context of professional roles Reaching for the ethical ceiling Aspirational ethics
  32. 32. Autonomy Beneficence Nonmaleficence Fidelity Justice
  33. 33. Ethical Culture of Social Workers  Service  Social Justice  Dignity and worth of the person  Importance of Human Relationships  Integrity  Competence
  34. 34.  Social workers elevate service to others above self interest.  Social workers draw on their knowledge, values, and skills to help people in need and to address social problems.  Social workers are encouraged to volunteer some portion of their professional skills with no expectation of significant financial return (pro bono service).
  35. 35.  Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people.  Social workers’ social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice.
  36. 36.  These activities seek to promote sensitivity to and knowledge about oppression and cultural and ethnic diversity.  Social workers strive to ensure access to needed information, services, and resources; equality of opportunity; and meaningful participation in decision making for all people.
  37. 37.  Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self determination.  Social workers seek to enhance clients’ capacity and opportunity to change and to address their own needs.
  38. 38.  Social workers are cognizant of their dual responsibility to clients and to the broader society.  They seek to resolve conflicts between clients’ interests and the broader society’s interests in a socially responsible manner consistent with the values, ethical principles, and ethical standards of the profession.
  39. 39.  Social workers understand that relationships between and among people are an important vehicle for change.  Social workers engage people as partners in the helping process.  Social workers seek to strengthen relationships among people in a purposeful effort to promote, restore, maintain, and enhance the wellbeing of individuals, families, social groups, organizations, and communities.
  40. 40.  Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in a manner consistent with them.  Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated.
  41. 41.  Social workers continually strive to increase their professional knowledge and skills and to apply them in practice.  Social workers should aspire to contribute to the knowledge base of the profession.
  42. 42.  The means to comply with a standard may not always be readily apparent  Two seemingly competing standards may appear equally appropriate  Application with of a single standard or set of standards appear consistent with one or more aspirational principle, but not another
  43. 43.  The social worker is the expert and has greater power in the relationship  Patient is vulnerable  The social worker is ultimately responsible for what happens in treatment
  44. 44.  Identify the competing ethical principles  Help to determine which principle has precedence and why  The importance of emotion in ethical decision-making and moral judgments  Cognitive biases are also important to consider
  45. 45. The NASW Code of Ethics does not include a model of ethical decision-making Other resources may aid with decision- making, but do not highlight how to work through dilemmas
  46. 46. S Scrutinize H Hypothesize A Analyze P Perform E Evaluate
  47. 47. 1. Goal is to define the problem by identifying the conflicting ethical principles 2. Generate a wide range of possible solutions and identify pros and cons 3. Merge or knit the possible solutions together in a way that maximizes the benefits and limits the disadvantages 4. Implement 5. Look back or evaluate
  48. 48. “integrative framework” steps two and three generate solutions that maximize your personal values within the context of your professional role
  49. 49. Avoid dichotomous thinking– either I have to do x or y. Duty to Warn example: either I have to warn the potential victim of a threat or I have to protect confidentiality.
  50. 50. 1. We have to train ourselves to think about larger ethical principles first 2. We need to have the ability to slow ourselves down prior to making good, ethical decisions Why?
  51. 51.  Malcolm Gladwell’s book “Blink”  Jonathan Haidt’s book on Moral Intuition  David Pizarro’s work on motivated moral reasoning
  52. 52.  Top down approach  Start with ethical principles  Work from those principles to make good decisions about our work
  53. 53.  Intuitive  Automatic  Emotional  Rapid
  54. 54. Why do psychologists (still and continue to) have sex with their patients?
  55. 55. Negative emotions related to ethical and moral decision-making Positive emotions related to our good decision-making skills and ethical knowledge  Fear  Anxiety  Disgust  Disrespect  Passion  Calmness/Centered  Empathy  Respect/Sympathy  Elevation
  56. 56.  The Fundamental Attribution Error  Actor Observer Bias  Availability Heuristic  Trait Negativity Bias  Confirmation Bias  Competence Bias
  57. 57.  This cognitive style places an undue emphasis on the patient’s behavior in the therapeutic relationship  Overemphasis on the patient  Psychologist may lack insight into what s/he is doing to promote those responses
  58. 58.  This cognitive style places an undue emphasis on external factors for the psychologist’s behavior  In an attempt to avoid responsibility, the psychologist can overemphasize the patient’s role in the ethical dilemma.
  59. 59.  This cognitive error leads one to use information that readily comes to mind or easiest to access  Easiest to go with that which is most representative of the patient or scenario
  60. 60.  When the psychologist more readily recalls unpleasant characteristics of the patient as compared with positive characteristics of the patient  It is common for psychologists to work with individuals they do not like or enjoy
  61. 61.  The cognitive style in which psychologists look for evidence to confirm their beliefs about the patient or the situation.  Motivated moral reasoning
  62. 62.  Dunning-Kruger Effect: a cognitive bias in which unskilled individuals suffer from illusory superiority, mistakenly rating their ability as much higher than average.  Poor performers fail to learn from their mistakes.  And, they fail to internalize direct feedback from others.
  63. 63.  Length of time in treatment  Patient complexity  Emotional intensity/therapeutic relationship  Current focus (or lack thereof) in treatment
  64. 64. A Brief Review
  65. 65.  Knowledge base: NASW code, foundational principles, state law, regulation, case law  Become aware of emotional factors  Remain aware of cognitive biases/situational factors  Patient/relationship factors  Outcomes are uncertain – Ambiguity remains
  66. 66. Emotions Decision- making Skills Cognitive Biases External Rules Personal Ethics Psychologist Complexity Length of time in treatment Current focus in treatment Boundaries Patient Variables Therapeutic Alliance
  67. 67. Why study ethics and ethical decision-making as a part of clinical practice?
  68. 68.  Fiduciary Responsibility  Providing the highest quality of care possible  Reinforcing doing the best possible for your patient  Better treatment outcomes
  69. 69. Independent Actions Help from others  Self Reflection  Documentation  Transparency  Continuing Education  Self-care  Consultation  Supervision  Psychotherapy  Continuing Education
  70. 70.  Good general basis to contemplate and discuss ethical issues in psychological practice  Look at vignettes as training tools  Remain aware of ethical issues in your practice and work on skill building
  71. 71. The need for informed consent Not just for the beginning of psychotherapy
  72. 72.  What does the law say?  What do the ethical principles suggest?  Usually a conflict between confidentiality and (community) beneficence  Child abuse reporting guidelines
  73. 73. What is the difference between a boundary crossing and a boundary violation?
  74. 74.  Sexual prohibitions  Physical prohibitions  Self-disclosure  The treatment frame
  75. 75.  Between session contacts  Digital boundaries and virtual ethics  Multiple roles (therapist, customer, etc.)
  76. 76. Ethics and Psychology