The Center For Ethical Practice

Oops! What Now? Ethical Dilemmas With Difficult Patients

Sun, 12 Feb 2012 00:13:45 +0000

Certain categories of patients create difficult ethical dilemmas for therapists. Using information from the research literature, as well as our own experience of various types of patients, how can we anticipate the predictable dilemmas, avoid the avoidable ones, and respond ethically to the “unavoidables”?

I. Potential Pitfalls & Ethical Dilemmas With Various Patients

Depressed

Anxious/Fearful

Angry/Rageful

Clinging/Dependent

Demanding/Entitled

Detached

Ambivalent

“Characterologically Difficult”

………………

II. Avoiding the “Avoidable” Ethical Dilemmas

Conscientiously Following Ethical Standards

Maintaining Clear Boundaries

Respecting Informed Consent Rights

Obtaining Consultation

Respecting Autonomy (Empowered Collaboration)

Attending to Documentation

Using “Redundant Protections” When Appropriate

III. Anticipating & Preparing for the “Unavoidable” Ethical Dilemmas

IV. Recognizing One’s Own Vulnerabilities With Certain Patients

Screening and Choosing Patients

Noticing Danger Signals

Recognizing Personal “Red Flags”

Following Your Own Ethical Compass

Sun, 12 Feb 2012 00:02:58 +0000

Following Your Own Ethical Compass:
Avoiding Law-Based Mindsets, Risk-Management Mindsets
& Anxiety-Based Behavior

We waste a lot of energy and create a lot of unnecessary anxiety when we adopt a solely risk-management position, because it leads us to focus on on possible risks to ourselves. Instead, we must give priority to an ethics-based mindset which leads us to focus on avoiding the risks to patients — which is the best risk-management strategy, anyway! So how can we hone our own ethical compass?

OUTLINE

I. Clarifying Your Profession’s “Ethical Floor”

II. Determining Your Own “Ethical Ceiling”

A. Considering Available Professional Recommendations
B. Weighing & Choosing Personal Options Beyond Those Recommendations

III. Constructing Clear Policies That Fit Your Own Practice

A. Policies in Private Practice
B. Policies in Group Practices
C. Policies in Agencies & Organizations

IV. Recognizing & Avoiding “Law-Based” Mindsets

A. Learning Relevant Laws
B. Learning to Place Laws Into Ethical Context

V. Recognizing & Avoiding “Risk-Management” Mindsets

A. Focusing on Preventing Risks to Patients Instead of Risks to Self
B. Dealing With Anxiety About Complaints or Malpractice Suits

VI. Developing Strategies for Maintaining the Ethical Focus

A. Regularly Reviewing/Assessing/Revising/Updating Your Policies & Practices
B. Consulting and Collaborating With Others Who Share Your “Ethical Ceiling”

Therapist Self-Disclosure

Wed, 30 Nov 2011 14:21:37 +0000

Therapists have many different opinions about self-disclosure with their patients. But regardless of your theoretical orientation or type of service, are there certain types of self-disclosure that are likely to be inappropriate in clinical relationships? We will explore the possibilities and test their potential consequences to the clinical process.

Monday, February 27, 2012
DoubleTree Hotel – Charlottesville VA
9:00 a.m. – noon

I. Ethical & Professional Guidelines

II. Types of Self-Disclosure

A. Volunteering Certain Information to All Patients
B. Volunteering Certain Information Only to Selected Patients
C. Responding to Patients’ Direct Questions
D. Using Self-References for Clinical Reasons
E. Using Self-References for Personal Reasons

III. Pitfalls Related to Self-Disclosure

A. Ethical Pitfalls
B. Clinical Pitfalls
C. Personal Pitfalls

IV. Obtaining Consultation for Making Planned Self-Disclosure Decisions

A. Sharing Information Related to Planned Voluntary Absences
B. Sharing Information Related to Pregnancy/Surgery/Illness
C. Sharing Information About a Planned Wedding/Divorce
D. Sharing Information About Future Professional Plans
E. Sharing Information If Therapist Moves or Closes a Practice
F. Other

V. Separating Your “Breakable Rules” From the “Unbreakable Rules”

A. Naming Your “Unbreakable” Self-Disclosure Rules
B. Acknowledging the Self-Disclosure Rules You Consider “Breakable”

EDUCATIONAL GOALS
(a) Describe your profession’s ethical standards and guidelines about self-disclosure
(b) List some ethical, clinical, and personal pitfalls related to self-disclosure
(c) Name your own “breakable rules” and “unbreakable rules” about self-disclosure

Revising Our LanguageAbout Informed Consent

Wed, 30 Nov 2011 14:21:20 +0000

Does our language about informed consent create confusion about it? Therapists and other mental health professionals often ask how they should “deliver” or “give” informed consent to patients. But in fact, informed consent is something you receive — “consent from an informed patient.” This workshop lets us practice fitting our language to the concept as we consider the what/when/how of informed consent, whether in the initial interview, or when subsequently obtaining consent for something.

INTRODUCTION:
Confused Language & Frequent Misunderstandings
About Informed Consent

1. Ethical Standards

2. The Concept of ”Truly Informed Consent”

3. Informing the Patient

What must we inform patients about?

How much information is necessary?

Must the information be presented in writing?

4. Obtaining the Informed Patient’s Consent

Consent to Receive Services

Consent to Accept the Described Policies and Fees

Consent to Accept the Described Limits of Confidentiality

Consent to Release Confidential Information to Others

Other Consent Circumstances

5. Other Ethical Implications

Preparing to Inform Patients

Aware of Ethical Requirements About What Information to Provide

Prepared to Incorporate Information re: Relevant Laws & Regulations

Assessing Patient’s Capacity to Understand the Information

Assessing Patient’s Capacity to Give Consent

EDUCATIONAL GOALS:
1. Describing and describing the informed consent process
2. Listing therapists’ responsibilities in that process
3. Naming some of the ethical implications and pitfalls related to informed consent in various contexts

Therapist Duties vs.Patient Responsibilities

Wed, 30 Nov 2011 14:21:07 +0000

Where do our professional duties end and our patients’ responsibilities begin? In this workshop we will focus on some of the ethical dilemma that might raise this question. For example, if a patient needs hospitalization, what scales do we use for balancing the ethical principle of beneficence against the duty to foster patient autonomy? What factors are important when deciding whether to terminate therapy, even if the patient objects?

Friday, March 9, 2012
Hilton Garden Inn – Fairfax VA
9:00 – noon

INTRODUCTION
“Balancing” Therapist Duties and Patient Responsibilities

I. Beginning the Therapy Relationship

A. Therapist’s Duty To Discuss at Intake (Informed Consent Interview)

Confidentiality and its limits

Reimbursement

Duration of therapy

Explaining Potential reasons for termination

B. Others’ responsibilities (agency involvement, family collaterals, etc.)

C. Patient’s Responsibilities

Consent to accept therapist’s policies as described

Participate in goal-setting

II. Continuing the Therapy Relationship

A. Therapist’s Duties

Being available in emergencies or alternate plan

Providing services appropriate to problem

As appropriate, re-opening issues discussed in informed consent interview

B. Patient’s Responsibilities

Abide by initial agreements re policies, payment, behavior

Attend scheduled therapy sessions

Participate in therapy process

III. Ending the Therapy Relationship

A. Therapist’s Duties

Discuss termination throughout treatment, as appropriate

Plan sessions for processing termination issues before ending

End relationship

B. Patients’ Responsibilities

IV. Special Considerations

A. Third Party Referral Considerations

B. Third Party Reimbursement Considerations

C. Patients’ Threats Toward Therapist

D. Patient-Initiated Premature Termination

E. Therapist-Initiated Termination vs. Abandonment

EDUCATIONAL GOALS:
1. Compare and contrast therapists’ duties with patients’ responsibilities
2. Name some of the issues which might arise that require weighing of various ethical principles
3. Use case vignettes to practice ways of dealing with such issues

Avoiding Slippery Slopes

Wed, 30 Nov 2011 14:20:52 +0000

This is not a risk-management workshop.
But we know that sometimes making exceptions to our usual ethical and clinical practices
can start us on a path from which it can be very hard to recover,
and which can ultimately affect the clinical outcome and patient welfare.
How can we recognize when we are about to take a step we will later regret?
Where are we each most vulnerable?
What support and reminders would be most helpful?

Friday, March 9, 2012
Hilton Garden Inn – Fairfax VA
1:00 – 4:00

I. Establishing Clear Policies

II. Living Up to Our Informed Consent Promises

III. Avoiding the Predictable Pitfalls

A. Temptations to Breach Confidentiality Unethically
B. “Avoidable” Conflicts of Interest
C. Pulls Toward Problematic Dual Relationships
D. Real or Perceived Boundary Violations

IV. Monitoring Our Current State

A. Personal Stressors Leading to Therapist Over-Disclosure
B. Unmet Need for Support
C. Inadequate Self-Care Leading to Tired/Sleepy/Burned-Out Therapist
D. Unmet Need for Therapy

V. Acknowledging Our Clinical Limitations

VI. Acknowledging Our Personal Vulnerabilities

VII. Understanding the Consequences for Patients

Ethical Issues in Assessment

Wed, 17 Aug 2011 01:21:26 +0000

For mental health professionals who provide assessment services, there are some specific ethical considerations. This is true whether they are in a private practice, in an agency or school setting, or within a forensic setting.

OUTLINE

1. Ethical Standards

2. Competence – Acquiring It & Maintaining It

Personal Competence

Professional Competence

Using Up-to-Date Tests & Methods

3. Informing Patients/Clients & Obtaining Consent

Informing About Nature & Purpose of the Assessment

Informing About Confidentiality Limits & Potential Disclosures

Informing About Fees/Payment

Informing About any Third Party Involvement

4. Providing Accurate and Adequate Feedback

5. Providing Access to Test Reports & Data

By Patient/Client

By Others

6. Other Ethical Issues in Assessment

Online Assessments

Automated Tests & Computerized Scoring

Third Party Referrals and/or Contracts

Security of Test Materials

Potential for Harm

EDUCATIONAL GOALS:
1. Describe the Ethical Standards that especially apply in assessment cases.
2. List the essential components of informed consent discussions in assessment cases.
3. Name three potential ethical pitfalls in conducting assessments.
4. Use clinical vignettes to review ways of avoiding those pitfalls when possible

Ethical & Legal Issues in Couple/Family Therapy

Tue, 16 Aug 2011 19:45:46 +0000

When working with multiple-party cases, some specific ethical and legal issues must be considered. Therapists who proceed without careful forethought and advance planning may be in for some ethical pitfalls down the road.

INTRODUCTION:
Ethical Implications of How We
Conceptualize a Couple or Family Therapy Case

I. “What Are My Ethical Responsibilities to Each Party in This Case?”

A. Multiple-Client Therapy (Couple, Family)

How does multi-client therapy differ from “individual therapy with collaterals” ?

Ethically? Legally? Clinically?

Who gets to decide? Who must you tell? What do you say to third party payers?

B. Child/Adolescent Therapy

Are parents actively involved? If so, are they also “clients”?

What are the rules about disclosure of information to parents/others?

Who gets to decide? What will you explain? To whom must you explain?

C. Collateral Participants

What is the therapist’s relationship with the collateral(s) or consultee(s)

What are the rights of those parties?

What ethical responsibilities does the therapist have to those parties?

How does this affect the rights of the primary client?

II. How Do Third-Party Referrals/Contracts Affect “Client” Status?

A. Employee Contracts – Must you accept your employer’s definitions of “client” ?

B. Managed Care Contracts – Do they affect your ethical definition of “client”?

C. Creating Personalized Contracts for Clarifying Relationships & Responsibilities

Contracts With Agencies (e.g., DSS, Court, Schools, Other)

Consultation Contracts (e.g., Corporate Training, Coaching, Assessment)

EDUCATIONAL GOALS:
1. Learn the ethical and professional standards that might especially apply in couples therapy.
2. Learn Virginia laws and regulations that affect couples therapy.
3. Apply these standards when considering practical issues that arise in your work with couples.
4. Understand some of the avoidable ethical and legal pitfalls when providing couples therapy.

Money Matters! (3 hour workshop)

Tue, 16 Aug 2011 19:29:32 +0000

This workshop is about an area of practice neglected in graduate training programs and still treated in some circles as a “taboo” topic for therapists and other mental health professionals. It is appropriate for any mental health professional who is in (or is planning to be in) independent practice, whether individual or group. It also raises ethical issues relevant to those who work in settings where others are making the business decisions about money.

Introduction:
Ethical & Professional Implications of Financial Decisions in Mental Health Practice

I. Ethical Standards Affecting Financial Decisions

II. Legal Regulations & Third Party Contracts Affecting Financial Decisions

III. Personal Money Issues That Can Cloud Business Decisions

IV. Weighing the Ethical & Legal Implications of Your Own Financial Policies

V. Developing Ethical Policies vs. “Following the Crowd”

Setting Fees
Billing Patients
Billing Third Parties
Collecting Unpaid Fees

VI. “Speaking of Money…..” – Explaining Your Policies to Clients (Informed Consent)

EDUCATIONAL GOALS:
1. Describe the Ethical Standards and professional guidelines related to financial decisions
2. Describe some of the legal regulations that affect financial decisions in clinical practice
3. Weigh your own policies against these Ethical/professional Standards and legal regulations.

Revising Our Language About Informed Consent

Tue, 16 Aug 2011 11:40:57 +0000

INTRODUCTION:
Confused Language & Frequent Misunderstandings
About Informed Consent

1. Ethical Standards

2. The Concept of ”Truly Informed Consent”

3. Informing the Patient

What must we inform patients about?

How much information is necessary?

Must the information be presented in writing?

4. Obtaining the Informed Patient’s Consent

Consent to Receive Services

Consent to Accept the Described Policies and Fees

Consent to Accept the Described Limits of Confidentiality

Consent to Release Confidential Information to Others

Other Consent Circumstances

5. Other Ethical Implications

Preparing to Inform Patients

Aware of Ethical Requirements About What Information to Provide

Prepared to Incorporate Information re: Relevant Laws & Regulations

Assessing Patient’s Capacity to Understand the Information

Assessing Patient’s Capacity to Give Consent