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Distance is the Best Armor


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Distance is the Best Armor: Ethical Decision-making in Clinical Practice

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Distance is the Best Armor

  1. 1. Distance is the Best Armor Ethical Decision-making in Clinical Practice John D. Gavazzi, Psy.D., ABPP
  2. 2. Objectives <ul><li>Learn the most frequently asked questions of APA’s Ethics Committee. </li></ul><ul><li>Understand one model of ethical decision-making. </li></ul><ul><li>Heighten awareness regarding multiple relationships. </li></ul><ul><li>Identify forensic issues related to the practice of psychology. </li></ul><ul><li>Recognize confidentiality issues in a variety of settings </li></ul>
  3. 3. Ethics <ul><ul><ul><li>Personal ethics </li></ul></ul></ul><ul><ul><ul><li>Higher moral principles </li></ul></ul></ul><ul><ul><ul><li>Ethical codes/principles </li></ul></ul></ul><ul><ul><ul><li>Ethics as law </li></ul></ul></ul>
  4. 4. Goals of the Ethical Codes <ul><li>To educate and guide ethical decision-making </li></ul><ul><li>To provide a clear statement about what contributes to unethical behavior </li></ul>
  5. 5. Difficulties with ethics codes <ul><li>There are approximately 100 enforceable standards </li></ul><ul><li>Codes do keep current (e.g., online psychotherapy) </li></ul><ul><li>Codes are not always clear and may contain conflicting information </li></ul>
  6. 6. Autonomy <ul><li>It encompasses freedom of thought and action. Individuals are at liberty to behave as they chose. </li></ul><ul><li>- Determining goals in therapy </li></ul><ul><li>- Making decisions (e.g., marriage) </li></ul><ul><li>- Terminating treatment </li></ul>
  7. 7. Versus <ul><li>Authoritarianism </li></ul><ul><li>Laissez-Faire </li></ul>
  8. 8. Beneficence <ul><li>The principle of benefiting others and accepting the responsibility to do good underlies the profession. </li></ul><ul><li>- Providing the best treatment possible </li></ul><ul><li>- Refer when needed </li></ul>
  9. 9. Nonmaleficence <ul><li>The principle is doing no harm. </li></ul><ul><li>- Not using an experimental technique as the first line of treatment </li></ul><ul><li>- Providing benefits, risks, and costs </li></ul>
  10. 10. Versus <ul><li>Non-productive therapy </li></ul><ul><li>Iatrogenic effects of therapy </li></ul>
  11. 11. Fidelity <ul><li>This principle refers to being faithful to commitments. Fidelity includes promise keeping, trustworthiness, and loyalty. </li></ul><ul><li>- Avoid conflicts of interests that could compromise therapy </li></ul><ul><li>- Therapeutic contract (e.g., session length, time, attention) </li></ul>
  12. 12. Versus <ul><li>Divided Loyalties </li></ul><ul><li>Lack of informed consent </li></ul>
  13. 13. Risks <ul><li>Ethics Committees </li></ul><ul><li>Licensing Board </li></ul><ul><li>Civil Litigation </li></ul><ul><li>Criminal Court </li></ul>
  14. 14. APA Ethics Office – FAQs <ul><li>Release of records (subpoenas & raw test data to attorneys) </li></ul><ul><li>Multiple/sexual relationships between client- therapist </li></ul><ul><li>Multiple relationship/sexual boundaries with supervision </li></ul><ul><li>Abrupt termination (clinic restructuring, managed care) </li></ul><ul><li>Forensic/custody matters </li></ul><ul><li>Test security </li></ul><ul><li>Confidentiality (breaches and issues between and within institutions) </li></ul>
  15. 15. APA Ethics Cases <ul><li>Felony Conviction </li></ul><ul><li>Loss of license </li></ul><ul><li>Sexual misconduct/Multiple relationships </li></ul><ul><li>Child Custody </li></ul><ul><li>Practicing outside area of competence </li></ul>
  16. 16. Malpractice Carriers <ul><li>Sexual misconduct/Multiple relationships </li></ul><ul><li>Custody Evaluations </li></ul><ul><li>Practicing outside area of competence </li></ul>
  17. 17. State/Provincial Boards of Psychology <ul><li>Unlicensed practice of psychology </li></ul><ul><li>Multiple relationships </li></ul><ul><li>Custody Evaluations </li></ul><ul><li>Practice outside area of competence </li></ul><ul><li>False representations (misleading advertising) </li></ul>
  18. 18. Ethical Decision-Making: A Problem-Solving Approach <ul><li>1. Describe the parameters of the situation& define potential issues </li></ul><ul><li>2. Consult the guidelines (APA Ethics Code, State Licensing Law) </li></ul><ul><li>3. Generate the alternative decisions possible for each issue. </li></ul><ul><li>4. Enumerate the consequences of making each decision. </li></ul><ul><li>5. Consult with a colleague </li></ul><ul><li>6. Make the decision. </li></ul><ul><li>7. Document your decision-making process and any consultations that you obtained </li></ul>
  19. 19. Boundaries Definitions, External Boundary Issues, & Internal Boundary Issues
  20. 20. Principles Related to Boundaries <ul><li>Not all boundary crossings are problematic. </li></ul><ul><li>Some boundary crossings are always wrong and/or prohibited. </li></ul><ul><li>It is impossible to avoid all boundary crossings. </li></ul><ul><li>Evaluation of boundary crossings can be helped by the principles that underlie our ethics code. </li></ul>
  21. 21. External Boundary Issues <ul><li>Working within limited or small social networks </li></ul><ul><li>Working in certain settings </li></ul><ul><li>Forensic versus Clinical Roles </li></ul><ul><li>Supervisors </li></ul>
  22. 22. Internal Boundary Issues <ul><li>Non-therapeutic self-disclosure </li></ul><ul><li>Psychological voyeurism </li></ul><ul><li>Intrusive advocacy </li></ul><ul><li>Allowing patients certain advantages </li></ul><ul><li>Selling products to patients </li></ul><ul><li>Touching and hugging </li></ul>
  23. 23. Helpful Tips <ul><li>Psychologists should avoid dual-role and conflict-of-interest relationships. </li></ul><ul><li>Sexually intimate behavior with patients is a serious boundary violation with possible legal and ethical consequences. </li></ul><ul><li>Psychologists need to carefully monitor rationalizations when faced with multiple roles and seek assistance before blending roles. </li></ul><ul><li>Psychologists need to recognize their own feelings toward each patient and how these feelings may interfere with psychotherapy. Seek supervision or consultation if you are engaging in these behaviors. </li></ul>
  24. 24. Group Exercise Boundaries
  25. 25. Forensic Issues Responding to Subpoenas, Releasing Raw Data, Custody Evaluations, & Forensic and Clinical Roles
  26. 26. Responding to Subpoenas <ul><li>Subpoenas are a legal demand for information; authorized by a court and served by attorney. </li></ul><ul><li>Subpoenas can be issued without the knowledge of the patient. </li></ul><ul><li>Subpoenas should not be ignored </li></ul>
  27. 27. Responding to Subpoenas <ul><li>Advise the patient and the patient’s attorney. </li></ul><ul><li>Obtain a written release of information. </li></ul><ul><li>If patient refuses, communicate the refusal in writing to the party requesting information. </li></ul>
  28. 28. Releasing Raw Data <ul><li>Test scores, stimuli, and patient responses; not raw handwritten notes </li></ul><ul><li>Possible misuse of data (e.g., erroneous conclusions, responses taken out of context) </li></ul><ul><li>Raw data (stimuli, test questions) may become part of the public domain. </li></ul><ul><li>Raw data can be released to a qualified psychologist who is working with a non-psychologist professional (with appropriate release of information). </li></ul>
  29. 29. Custody Evaluations <ul><li>Highly specialized and complex process </li></ul><ul><li>Refer to APA’s Guidelines for Child Custody Evaluations in Divorce Proceedings </li></ul><ul><li>PPA’s Child Custody Project Group </li></ul><ul><li>Need a high level of training, skills, and supervision to perform competently </li></ul>
  30. 30. Clinical vs. Forensic Roles <ul><li>See Chart on last page of handout </li></ul><ul><li>Blending clinical and forensic roles must be avoided. </li></ul><ul><li>Be clear at the outset of the relationship what your role is and what your responsibilities are. </li></ul>
  31. 31. Group Exercise Forensic Issues
  32. 32. Confidentiality Privacy, Privilege, and Confidentiality
  33. 33. Privacy <ul><li>A basic right granted by the 4th ammendment of the Constitution to decide how much of a person’s thoughts, feelings, or personal data should be shared with others. </li></ul>
  34. 34. Privilege <ul><li>A legal term that prevents disclosing information in court or other legal proceedings because that information was gathered in a special relationship. </li></ul><ul><li>The patient has the privilege and can waive it. </li></ul>
  35. 35. Confidentiality <ul><li>A professional standard of conduct that obliges the psychologist from discussing information with anyone. </li></ul><ul><li>Confidentiality is a cornerstone of psychotherapy. </li></ul>
  36. 36. Breaches of Confidence <ul><li>Duty to Warn </li></ul><ul><li>Patient Welfare/Safety </li></ul><ul><li>Mandated child abuse </li></ul>
  37. 37. Helpful Tips <ul><li>Psychologist knowledge of general principles and issues is crucial </li></ul><ul><li>Informed consent at the beginning of treatment is essential. </li></ul><ul><li>Prior to releasing any records or general information, a written release of information is usually necessary. </li></ul>
  38. 38. Helpful Tips <ul><li>There is a “need to know” basis when releasing records. Record keeping becomes an issue. </li></ul><ul><li>Special considerations need to be made for rights of minors and legally incompetent individuals. </li></ul>
  39. 39. Group Exercise Confidentiality
  40. 40. Wrap Up Question & Answer Evaluation Forms