This document provides an agenda and materials for an ethics training presentation. The presentation aims to help participants differentiate between clinical, legal, and risk management issues, define common risk management strategies, and explain how competing ethical principles can create dilemmas. It includes slides on key ethical principles, codes, risk management strategies, documentation, informed consent, and working with clinical dilemmas. Case examples will also be discussed and analyzed from an ethical perspective. The goal is for participants to learn how to make ethical clinical decisions that balance patient welfare, competence, and legal/risk management concerns.

1. John D. Gavazzi, PsyD ABPP
Psychologist
Ethics Educator
TW Ponessa and Associates
August 22, 2014

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3. At the end of the presentation, the participant
will be able to:
1. Differentiate between clinical and legal
issues
2. Define common risk management strategies
3. Explain how two competing ethical
principles can create an ethical dilemma

4. Quick Review of Ethical Codes and
Foundational Principles
Define clinical, legal, risk management
and ethical issues
Risk Management as Quality Enhancement
Vignette Analysis

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

6. Autonomy
Beneficence
Nonmaleficence
Fidelity
Justice

7. Part of the Code of Ethics
Do no harm
Competence
Promote Welfare of
others
Communicate
Truthfully
Integrity of the
profession, avoid
damaging public trust
Collaboration &
positive working
relationships

8. Avoid harm
Multiple relationships
Informed Consent
Managing Boundaries
Documentation
Cultural Sensitivity
Careful with imposing
your values on others
Advocacy work
The Counseling Relationship

9. Respecting rights and
privacy
Couples/Family
Treatment
Informed Consent
Client access to records
Document/Records
Case Consultation
Storage and Disposal
of Records
Community
Beneficence -Danger
Confidentiality and Privacy

10. Competence
Specialization/CE
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Professional
Impairment
No Sexual Harassment
Nondiscrimination
Professional Responsibility

11. Client Welfare
Competence
Informed Consent
Diagnosis
Cultural Sensitivity
Prejudice/Pathology
Appropriate
instruments
Forensic Issues
Evaluation, Assessment & Interpretation

12. Client Welfare
Competence
Informed Consent
Multicultural
Competence
Conflict of Interest
Boundary Issues
Sexual Issues
Teaching Ethics
Supervision, Training and Teaching

13. Clinical Decision-making
Risk management
Legal Decision-making
Ethical Decision-making
◦ Professional Ethics
◦ Personal Values and Morality

14. Rules of Conduct – Profession/society
More external – Community (of peers)
Easier means to judge others’ actions
Can constrain individual choices or create
dilemmas
Explicit/cognitive/external/measured

15. Personal moral compass-Believe it to be right
Knowing the difference between right and wrong
Emotional responses to dilemmas and actions
Implicit/rapid/automatic/internal/affective
Research shows people judge themselves and others
based on moral characteristics – evolutionary and
social reasons to judge “character”

17. 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?

18. 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 clinically
complex patients.
Do I have essential paperwork signed?
Informed Consent or practice policies current

19. 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

20. Professional Ethics
Do I follow my profession’s Code of Conduct?
Am I performing at the minimum or reaching
for the aspirational ceiling?
Is my behavior linked to a foundational
principle?

21. A False Risk Management Strategy
is an action or intervention that is
meant to reduce liability or harm,
but does not.
Ironically, some of these actions or
interventions likely hinder the
psychologist’s ability to provide
high quality of care.

22. False Risk Management
strategies do not connect to
overarching ethical principles

23. • Informed consent only occurs at the
beginning of treatment
• Informed consent mainly involves the
patient to sign forms for risk
management purposes

24. • Self-disclosure is never appropriate by
the psychologist during psychotherapy
or assessment
• Self-disclosure is clearly a boundary
violation that is always wrong

25. • When dealing with high risk patients, it is
better to not document a great deal of
information.
• If you do not document much detail, then
you have greater legal protection from an
attorney indicating that you did something
wrong. Attorneys can twist words easily,
so the less the better.

26. • This is an important risk management
strategy
• This is the standard of care
• This strategy helps the patient from
actually harming him or herself.

27. • Psychotherapy is like other polite
conversations, so it is improper to talk
about religion.
• Mental Health professionals are not
sufficiently trained in religious matters.
• The best strategy is to refer patients to
their priest, pastor, rabbi or spiritual guide

28. Positive Ethics and Risk Management

29. Documentation
Empowered Collaboration
Consultation
Redundant Protections

30. Required by insurers, State Boards,
Professional Organizations, etc.
Standard of Care
A record of treatment for future providers
Useful risk management tool

31. Dialogue with self and patient regarding
process and goals of treatment
Means to identify pertinent clinical issues
Procedure to document progress
Can Use to help patients see progress

32. MHPs respect patient autonomy and decisions
regarding goals and process of treatment
Empowered collaboration builds upon
informed consent

33. Empowered collaboration maximizes
patient participation in the decision-making
process
Patient involvement in goal setting and
treatment planning
MHP refrains from giving opinions and
helps the patient work through ambivalence

34. Technical-oriented information
Emotional reactions (countertransference)
Reduction of emotional turmoil
Thinking through solution together

35. Write down issues in advance
Need to be open and honest
Be willing to admit mistakes or clinical
errors

36. Redundant Protections

37. Additional sources of information
◦ Contact PCP
◦ Collateral session with family members
◦ Prior evaluations
Supervision or Consultation
◦ Legal consultation
◦ Group or Individual
Use of Psychotherapy notes to aid with self-reflection

38. 1. Does the patient think you
have a good working
relationship?
2. Do my patient and me share
the same treatment goals?
3. Does the patient report any
progress in therapy?
4. Does the patient want to
continue in treatment?
1. Do I believe I have a positive
working relationship with my
patient?
2. Is my assessment of the
patient sufficiently
comprehensive?
3. Do unresolved clinical issues
impede the course of
treatment?
4. Have I documented
appropriately?
Patient Collaboration Self-Reflection

39. General Rule
Implement quality enhancing strategies with as
much transparency as possible.

40. From real life ethical dilemmas in the mental
health field

41. Vignette Warehouse on Ethics and Psychology
site
www.ethicalpsychology.com

42. Vignette 1: Therapist in the Middle
You work in an outpatient treatment facility. Your patient
reveals, during the course of therapy, that a staff person
paid to have sex with another patient, who is a prostitute.
The staff member works in another department in the
agency. And, according to your patient, the patient
(prostitute ) not aware that one of her customers works in
another part of that facility.
You do not know the therapist well, but you participated
in a consultation group with the therapist in the past.
You do not dwell on the situation with the patient.
However, after the session, you feel uneasy about what
your patient revealed.
What are the clinical issues?
What are the risk management
concerns?
If you could ask a lawyer one
question, what would it be?
What are the ethical issues?

43. Vignette 2: Character Witness?
You receive a phone message from a patient. The patient
is asking for you to be a “character witness” as he has an
upcoming hearing for a minor criminal offense. His
attorney believes that some good, written character
references will really help out with the case.
You have worked with the 40-year-old male patient for
about a year. None of the treatment issues had to do
with impulse control or antisocial tendencies. Therapy
focused on depression and relationship issues. While the
patient attends appointments regularly, he never made
mention of any arrests or legal charges. He is likeable,
even charming. He wants to discuss this issue with you
at the next session.
What are the clinical issues?
What are the risk management
concerns?
If you could ask a lawyer one
question, what would it be?
What are the ethical issues?

44. Complete course evaluations