Distance is the Best Armor

Ethical Decision-making in Clinical Practice

John D. Gavazzi, Psy.D., ABPP

Donald Jennings, Ed.D

Objectives

Learn the most frequently asked questions of APA’s Ethics Committee.

Understand one model of ethical decision-making.Heighten awareness regarding multiple

relationships. Identify forensic issues related to the practice of

psychology.Recognize confidentiality issues in a variety of

settings

Ethics

Personal ethics

Higher moral principles

Ethical codes/principles

Ethics as law

Goals of the Ethical Codes

To educate and guide ethical decision-making

To provide a clear statement about what contributes to unethical behavior

Difficulties with ethics codes

There are approximately 100 enforceable standards

Codes do keep current (e.g., online psychotherapy)

Codes are not always clear and may contain conflicting information

Autonomy

It encompasses freedom of thought and action. Individuals are at liberty to behave as they chose.

- Determining goals in therapy

- Making decisions (e.g., marriage)

- Terminating treatment

Versus

Authoritarianism

Laissez-Faire

Beneficence

The principle of benefiting others and accepting the responsibility to do good underlies the profession.

- Providing the best treatment possible

- Refer when needed

Nonmaleficence

The principle is doing no harm.

- Not using an experimental technique as the first line of treatment

- Providing benefits, risks, and costs

Versus

Non-productive therapy

Iatrogenic effects of therapy

Fidelity

This principle refers to being faithful to commitments. Fidelity includes promise keeping, trustworthiness, and loyalty.

- Avoid conflicts of interests that could compromise therapy

- Therapeutic contract (e.g., session length, time, attention)

Versus

Divided Loyalties

Lack of informed consent

Risks

Ethics Committees

Licensing Board

Civil Litigation

Criminal Court

APA Ethics Office – FAQs

Release of records (subpoenas & raw test data to attorneys)

Multiple/sexual relationships between client- therapist Multiple relationship/sexual boundaries with supervision Abrupt termination (clinic restructuring, managed care) Forensic/custody matters Test security Confidentiality (breaches and issues between and within

institutions)

APA Ethics Cases

Felony Conviction

Loss of license

Sexual misconduct/Multiple relationships

Child Custody

Practicing outside area of competence

Malpractice Carriers

Sexual misconduct/Multiple relationships

Custody Evaluations

Practicing outside area of competence

State/Provincial Boards of Psychology

Unlicensed practice of psychology

Multiple relationships

Custody Evaluations

Practice outside area of competence

False representations (misleading advertising)

Ethical Decision-Making: A Problem-Solving Approach

1. Describe the parameters of the situation& define potential issues

2. Consult the guidelines (APA Ethics Code, State Licensing Law)

3. Generate the alternative decisions possible for each issue.

4. Enumerate the consequences of making each decision.

5. Consult with a colleague

6. Make the decision.

7. Document your decision-making process and any consultations that you obtained

Boundaries

Definitions,External Boundary Issues, & Internal Boundary Issues

Principles Related to Boundaries

Not all boundary crossings are problematic.

Some boundary crossings are always wrong and/or prohibited.

It is impossible to avoid all boundary crossings.

Evaluation of boundary crossings can be helped by the principles that underlie our ethics code.

External Boundary Issues

Working within limited or small social networks

Working in certain settingsForensic versus Clinical RolesSupervisors

Internal Boundary Issues

Non-therapeutic self-disclosurePsychological voyeurismIntrusive advocacyAllowing patients certain advantagesSelling products to patientsTouching and hugging

Helpful Tips

Psychologists should avoid dual-role and conflict-of-interest relationships.

Sexually intimate behavior with patients is a serious boundary violation with possible legal and ethical consequences.

Psychologists need to carefully monitor rationalizations when faced with multiple roles and seek assistance before blending roles.

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.

Group Exercise

Boundaries

Forensic Issues

Responding to Subpoenas, Releasing Raw Data, Custody

Evaluations, &Forensic and Clinical Roles

Responding to Subpoenas

Subpoenas are a legal demand for information; authorized by a court and served by attorney.

Subpoenas can be issued without the knowledge of the patient.

Subpoenas should not be ignored

Responding to Subpoenas

Advise the patient and the patient’s attorney.

Obtain a written release of information.

If patient refuses, communicate the refusal in writing to the party requesting information.

Releasing Raw Data

Test scores, stimuli, and patient responses; not raw handwritten notes

Possible misuse of data (e.g., erroneous conclusions, responses taken out of context)

Raw data (stimuli, test questions) may become part of the public domain.

Raw data can be released to a qualified psychologist who is working with a non-psychologist professional (with appropriate release of information).

Custody Evaluations

Highly specialized and complex process

Refer to APA’s Guidelines for Child Custody Evaluations in Divorce Proceedings

PPA’s Child Custody Project Group

Need a high level of training, skills, and supervision to perform competently

Clinical vs. Forensic Roles

See Chart on last page of handout

Blending clinical and forensic roles must be avoided.

Be clear at the outset of the relationship what your role is and what your responsibilities are.

Group Exercise

Forensic Issues

Confidentiality

Privacy, Privilege, and Confidentiality

Privacy

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.

Privilege

A legal term that prevents disclosing information in court or other legal proceedings because that information was gathered in a special relationship.

The patient has the privilege and can waive it.

Confidentiality

A professional standard of conduct that obliges the psychologist from discussing information with anyone.

Confidentiality is a cornerstone of psychotherapy.

Breaches of Confidence

Duty to Warn

Patient Welfare/Safety

Mandated child abuse

Helpful Tips

Psychologist knowledge of general principles and issues is crucial

Informed consent at the beginning of treatment is essential.

Prior to releasing any records or general information, a written release of information is usually necessary.

Helpful Tips

There is a “need to know” basis when releasing records. Record keeping becomes an issue.

Special considerations need to be made for rights of minors and legally incompetent individuals.

Group Exercise

Confidentiality

Wrap Up

Question & Answer

Evaluation Forms