This is a presentation for Springfield Psychological Associates, a group mental health practice in Southeastern Pennsylvania.

1. Intentional Ethics
Decision-making, Telehealth and
Social Media
John Gavazzi, PsyD, ABPP
November 2016
Springfield Psychological Association
john.gavazzi@gmail.com @Dr_Gavazzi

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3. Learning Objectives
1. List four of the five foundational ethical principles
of all mental health professions.
2. Describe how clinical and ethical decisions are
typically made.
3. Explain the clinical implications of a separated or
assimilated strategy.
4. Write two important components to ethical and
competent telehealth practice.
5. Explain two potential ethical pitfalls when
integrating social media into your practice.

5. General Outline
• Ethical Principles
• Ethical Acculturation Model
• Ideas about telehealth
• Social media concerns

6. Participant Safety
• Creating a safe environment
• Avoid the word “unethical”
• We are all learning in this process
• Demonstrate courtesy and respect for others
• We are all fallible

7. Assumptions in this presentation
• We all have different tolerances, biases, and
methods of making moral and ethical judgments
• We are all subject to biases, heuristics, and
erroneous thought processes. We do not think in
algorithms. We are all human.
• Using the same scenario, we can make clinically
sound and ethically appropriate decisions that differ
from one another. In other words, many times there
are multiple “correct” answers.

9. Personal moral compass-Knowing the difference
between right and wrong
Emotional responses to dilemmas and actions
Research shows that moral decisions are often rapid,
automatic, internal, affective, and nonconscious
Research shows people judge themselves and others
based on moral characteristics – evolutionary and
social reasons to judge “character”
Morality

10. Rules of Conduct – Profession/society
More external – Community (of peers) decides what
is appropriate or not
If we know the rules, it is easier to judge others’
actions against standards
Ethics codes can constrain individual choices or
create dilemmas
Ethical decision-making can be more conscious,
more cognitive, and measured externally
Ethics

11. Principle-Based Ethics
Underlying principles to all
healthcare professions

12. Autonomy
Beneficence
Nonmaleficence
Fidelity to Relationship
Justice
Principle-Based Ethics

13. Respect for Autonomy
• Does not mean promoting autonomy
(individuation or separation)
• Means respecting the autonomous decision
making ability of the patient

14. Autonomy
• It encompasses freedom of thought and action.
• Individuals are at liberty to behave as they
chose.
- Determining goals in therapy
- Making life decisions (e.g., marriage, divorce)
- Scheduling appointments and terminating treatment

15. Beneficence
• The principle of benefiting others and accepting
the responsibility to do good underlies the
profession.
- Providing the best treatment possible,
including evidence-based techniques
and treatment
- Competency
- Referring when needed

16. Nonmaleficence
The principle is doing no harm.
- Demonstrating competence
- Maintaining appropriate boundaries
- Not using an experimental technique as the
first line of treatment
- Providing benefits, risks, and costs

17. Fidelity
This principle refers to being faithful to
commitments. Fidelity includes promise
keeping, trustworthiness, and loyalty.
- Avoiding conflicts of interests that could
compromise therapy
- Keeping information confidential
- Adhering to therapeutic contract (e.g.,
session length, time, phone contacts, etc.)

18. Justice
Justice primarily refers to treating people fairly
and equally.
In their work-related activities, mental health
professionals do not engage in unfair discrimination
based on age, gender, gender identity, race, ethnicity,
culture, national origin, religion, sexual orientation,
disability, socioeconomic status, or any basis
proscribed by law.

19. Psychotherapy is inherently a
moral enterprise
- Beneficence
- Of good moral character
- Value-free psychotherapy does not exist

20. The Acculturation Model
One way of remaining a life-long
learner
Provides another way to discuss ethical
behaviors and decisions

21. Acculturation
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.

22. Ethics Acculturation Model
• An outgrowth of positive ethics that integrates
personal ethics and professional obligations.
• Each mental health profession has a system of
distinctive norms, beliefs, and traditions.
• This set of beliefs is reflected in the respective
ethics codes; especially the overarching ethical
principles.

23. Acculturation as a Process
• Can be a complex process
• Some parts of a mental health professional’s
practice and lifestyle may be easily
acculturated while others not
• Process that will likely continue throughout
the education or career as a mental health
professional

24. Ethical Acculturation
Identification with personal value system
(higher vs. lower)
Identification with professional value system
(higher vs. lower)

25. 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

26. Marginalized
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

27. Assimilation
Matrix: Higher on professional ethics
Lower on personal ethics
Risks: Developing an overly legalistic
stance
Rigidly conforming to certain
rules while missing broader
issues

28. Assimilated Strategies
• Assimilated strategy attempts to be prevention
focused
• Assimilated strategies are often “fear based” –
where motive to avoid harming another or
incurring punishment for oneself, causes the
mental health professional to adopt legalistic
stances, which may harm the therapeutic
relationship (e.g., no suicide contract)

29. Separation
Matrix: Lower on professional ethics
Higher on personal ethics
Risks: Compassion overrides good
professional judgment
Fail to recognize the unique
role of the mental health
professional

30. Separated Strategies
• Separated strategy attempts to be promotion
focused
• Separated strategies are often “benefits-based”
– where the motive for promoting the well-
being of the patient causes the mental health
professional to be blind to ways that well-
meaning people can cause harm (e.g., loaning
money to patients)

31. But both biases fail to give adequate
attention or weight to the overarching
ethical principles that guide or need to
guide professional behavior
Problem with both strategies in
terms of ethical and clinical
decision making.

32. Integrated
Matrix: Higher on professional ethics
Higher on personal ethics
Reward: Implement values in context
of professional roles
Reaching for the ethical
ceiling
Aspirational ethics

33. Ethical and Clinical Decision-
making
We think like defense attorneys
rather than court justices
Bottom up vs. Top Down

34. • Identify the competing ethical principles
• Help to determine which principle has
precedence and why
• The importance of emotion in ethical and
clinical decision-making
• Cognitive biases are also important to consider
Important points to remember

35. In certain situations, we need to
construct or create a solution
instead of looking up the answer
in a sacred treatment text

36. 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?
Major Point to this Training

37. There is an intuitive, non-rational
process in ethical decision-making
Why do mental health professionals (still and
continue to) have sex with their patients?

38. Research shows when emotions
run high, our judgments are
more likely to be extreme than
when our emotions are weak.
As MHPs, we know individuals
reason emotionally.
We, as MHPs, need to pay
attention to our emotions during
ethical & clinical decision-making.

40. Emotional Components
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

41. What can I do?
Independent Actions Help from others
• Self Reflection
• Documentation
• Transparency
• Continuing Education
• Self-care
• Consultation
• Supervision
• Psychotherapy
• Continuing Education

43. Questions and Answers
On to telehealth

45. Myths about Telehealth
• There is no research to support its use
• It is too expensive
• There is no insurance reimbursement
• There are no guidelines for telehealth
• It is impractical for individuals to get up and
running
• Telehealth means you have to use electronic
records

46. Telehealth Statistics
Patient Resistance to Telehealth Services

47. Telehealth Statistics
Patient Desire for Telehealth Services

48. • Increased client satisfaction
• Decrease costs with child/elder care
• Decrease travel time
• Improved access to specialists
• Improved attendance
• Potential for faster appointment
• Don’t have to use “sick time”
What are the patient benefits?

49. • Increased client satisfaction
• Improved attendance (weather, vehicles)
• Greater access to patients (geography)
• Can treat agoraphobic patients
• Potential for increase office efficiency
• Can deal with emergencies more effectively (and get
paid)
What are the benefits to the therapist?

50. • Need to be competent
• Need to know technology
• Treatment & rules are slightly different
• Higher risk treatment modalities
• Potential for problems can increase
• May need to spend more time with some patients to
get them up to speed with technology
Downsides of Telehealth?

51. Higher Risk Model
• Patient is at a greater geographic distance from
you.
• The patient lives alone
• You have never met the patient in person
• You and your patient live in different states, one
of which you are not licensed
• You promised treatment without an assessment

52. Migration Model
• Start with patients you already see in treatment.
• Consider clinical complexity
• If patient is complex and needs twice per week
sessions, consider using one session via
telehealth
• Not every patient is a candidate for telehealth

53. Migration Model
• Take time to prepare these patients.
• Consider their technological savvy
• Plan regular, in-person sessions as the norm
• Consider patient’s level of social support
• Pick a distance you feel comfortable

54. Migration Model
• Make sure you are approved by the patient’s
insurance company to provide services
• Make sure you understand the billing codes of
that insurance company before offering
telehealth services.

55. My Story
• Patients wanted to access teletherapy services
mainly for convenience
• Became approved provider for Highmark (and
now Capital Blue)
• Doxy.me is a free HIPAA-compliant platform
• Used the migration model successfully. One
exception.

56. Final Thoughts
• Assign a couple of individuals to take additional
training
• Informed Consent is different
• Internet security is important
• Be mindful of interjurisdictional practice
• Competence takes time and practice

57. Questions and Answers
On to Social Media

58. The Reality of the 21st Century
• Technology and Social Media have expanded
the ways in which individuals access
professionals and specific forms of
information, including health information.
• Many health professionals are building an
online presence and there are some issues to
contemplate about your online presence.
• It is likely best to align your online presence
with your general professional mission.

60. Quick exercise to see, literally, who is on
social media in general
Which platforms people are comfortable using
on a professional basis

62. Some Questions to Contemplate
• Why am I joining social media?
• What do I hope to accomplish?
• What image or brand am I trying to
develop? (if any)

63. Some Questions to
Contemplate
• How do I plan to develop it?
• What resources do I have, including time,
to invest?
• Do I understand the technology?

65. At the most basic level, you are trying to
develop a network of online connections in
which you can give and take information, and
possibly rebroadcast it to others.
There are cultural and evolutionary reasons as
to why you want to be social and connect with
others. Just not your patients.

66. 1. Do what you do
best
2. You do not need to
respond
3. Birds of a feather
Don’t try to tell jokes on
SM unless you are a
comedian
Expect a nasty or
unfavorable comment
every now and then
More likely to follow and
connect with others like
you
Basic Heuristics for Social Media

67. One-Way, Static Forms of Information
• Available 24/7
• Practice Information
▫ Appointments, practice information,
informed consent, HIPAA policy, etc.
• Expert Information
▫ Blog, FB, G+, posts, podcasts, Tweets,
YouTube videos, curating information

68. Two-Way Communication
• Social Media provides ways to
communicate back to individuals
• Know the technology before you use it.
▫ Facebook: Messenger System
▫ Twitter: Direct Message
▫ Tumblr: Messaging System
▫ LinkedIn: Messaging System

70. Ethics of Two-Way Communication
• Informed Consent
• When does a person in cyberspace become
a patient?
• HIPAA compliant communication?
• Do you have a social media policy?

71. Between Session Contacts via SM
• Informed Consent
• HIPAA compliant communication
• Googling or using social media to learn
more about your patients

72. Good General Heuristic
Keep your personal life separate from your
social life on social media
Avoid boundary crossings
Avoid boundary violations

73. Boundaries in Cyberspace
• Would you drive past your patient’s house
for any reason?
• Would you go to a patient’s party?
• Would you look into your patient’s
windows?

74. Possible Reasons for Joining Social
Media
• Altruism
• Ego Needs
• Educating Others
• Developing an Expertise
• Growing a Practice
• Make Money

76. Questions and Answers
Discussion
Course Evaluations