COMPS: 3 Professional Issues and Ethics

Competency for informed consent

Capacity: client has the ability to make rational decisions Comprehension of information: therapists must give clients information in a clear way and check to see that they understand in Voluntariness: person giving consent is acting freely in decision-making process and is legally/psychologically able (competent) to give consent

Professional standard of care

Commonly accepted by the profession, expected to possess/exercise knowledge, skills, and judgment common to other members of their profession Counselors have a responsibility to read, understand, and follow the Code of Ethics and the Standards of Practice. Boundaries of Competence. Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors will demonstrate a commitment to gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population. New Specialty Areas of Practice. Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and to protect others from possible harm. Qualified for Employment. Counselors accept employment only for positions for which they are qualified by education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors hire for professional counseling positions only individuals who are qualified and competent. Monitor Effectiveness. Counselors continually monitor their effectiveness as professionals and take steps to improve when necessary. Counselors in private practice take reasonable steps to seek out peer supervision to evaluate their efficacy as counselors. Ethical Issues Consultation. Counselors take reasonable steps to consult with other counselors or related professionals when they have questions regarding their ethical obligations or professional practice. Continuing Education. Counselors recognize the need for continuing education to maintain a reasonable level of awareness of current scientific and professional information in their fields of activity. They take steps to maintain competence in the skills they use, are open to new procedures, and keep current with the diverse and/or special populations with whom they work. Impairment. Counselors refrain from offering or accepting professional services when their physical, mental, or emotional problems are likely to harm a client or others. They are alert to the signs of impairment, seek assistance for problems, and, if necessary, limit, suspend, or terminate their professional responsibilities. Principle A: Beneficence and Nonmaleficence Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists' obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists' scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work. Principle B: Fidelity and Responsibility Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work. They are concerned about the ethical compliance of their colleagues' scientific and professional conduct. Psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage. Principle C: Integrity Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat, or engage in fraud, subterfuge, or intentional misrepresentation of fact. Psychologists strive to keep their promises and to avoid unwise or unclear commitments. In situations in which deception may be ethically justifiable to maximize benefits and minimize harm, psychologists have a serious obligation to consider the need for, the possible consequences of, and their responsibility to correct any resulting mistrust or other harmful effects that arise from the use of such techniques. Principle D: Justice Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices. Principle E: Respect for People's Rights and Dignity Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making. Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.

Striver Consultation

?

Ethical incompetence

Being unaware of code of ethics (in any professional organization), being unaware of laws pertaining to care of clients Departure from acceptable professional standards

Professional negligence

Going against the code of ethics, doing harm of any kind to a client, disclosing information (on purpose or by accident)

Dual relationships

Avoid When Possible. Counselors are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of clients. Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. (Examples of such relationships include, but are not limited to, familial, social, financial, business, or close personal relationships with clients.) When a dual relationship cannot be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (See F.1.b.) Superior/Subordinate Relationships. Counselors do not accept as clients superiors or subordinates with whom they have administrative, supervisory, or evaluative relationships. A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code. (c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (See also Standards 3.04, Avoiding Harm, and 3.07, Third-Party Requests for Services.)

Malpractice

Bad practice", failure to render professional services or to exercise the degree of skill that is ordinarily expected of other professionals in a similar situation To succeed malpractice claim, must have 4 elements: Professional relationship between therapist and client must exist Therapist must have acted in negligent or improper manner; have deviated from the "standard of care" by not providing services considered "standard practice with the community" Client must have suffered harm or injury, which must be demonstrated Must be a legally demonstrated causal relationship between practitioner's negligence or breach of duty and the damage or injury claimed by the client Malpractice limited to 6 kinds of situations: Procedure not within realm of accepted professional practice Employ a technique he/she not trained to use Did not use a procedure that would have been more helpful Failed to warn others and protect them from violent crime Informed consent not obtained/documented Consequences to treatment not explained Possible extra-client abandonment//misdiagnosis//repress-false memories//unhealthy transference relationships//sexual misconduct Physical contact or sexual relations with patients Improper release of hospitalized patients Failure to supervise students or assistants Abandonment of patient Basic precautions to decrease liability in practice are Define realistically your areas of expertise Maintain competency Chose and handle patients carefully Terminate treatment carefully Follow up when an unusual incident occurs in treatment Keep complete record Risk management: be aware of states' regulations, information that must be kept, well-documented explanations of everything done for/with client, consult when necessary Treat lawsuit seriously, do not continue relationship w/that client Find out about support you have through professional agencies, supervisors, etc. Speak w/attorney only Legal liability for improper treatment trough civil law constitutes malpractice

What goes in progress notes?

Basic part of clinical records, is required Diagnosis, functional status, symptoms, treatment plans, consequences, alternative treatments, and client progress Professional (writings could be seen by client/court) May be requested by client at any time Required by law to keep record on all clients thru progress notes, not required to keep process notes "If it's not documented, it never happened." Case notes should never be altered/tampered after entered into client records Enter notes as soon as possible and sign/date entry Process/psychotherapist notes deal w/client reactions such as transference and therapist's subjective impressions of client; intimate details about client, details of dreams/fantasies, sensitive information about client's personal life, therapists' own thoughts, feelings, and reactions to client 6.01 Documentation of Professional and Scientific Work and Maintenance of Records Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analyses, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law. 6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work (a) Psychologists maintain confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium. (b) If confidential information concerning recipients of psychological services is entered into databases or systems of records available to persons whose access has not been consented to by the recipient, psychologists use coding or other techniques to avoid the inclusion of personal identifiers. (c) Psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists' withdrawal from positions or practice

Sexually involved between counselor and client

Current Clients. Counselors do not have any type of sexual intimacies with clients and do not counsel persons with whom they have had a sexual relationship. Former Clients. Counselors do not engage in sexual intimacies with former clients within a minimum of 2 years after terminating the counseling relationship. Counselors who engage in such relationship after 2 years following termination have the responsibility to examine and document thoroughly that such relations did not have an exploitative nature, based on factors such as duration of counseling, amount of time since counseling, termination circumstances, client's personal history and mental status, adverse impact on the client, and actions by the counselor suggesting a plan to initiate a sexual relationship with the client after termination. The rigid attitude toward boundary crossings stems in part from what Dineen (1996) called 'sexualizing boundaries." This is a skewed view that sees all boundary crossings as sexual in nature as illustrated in the slippery slope argument. Simon (1991), for example, decrees that: "The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself" (p. 614). Similarly, Pope (1990) states " . . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships" (p. 688). These unreasonable beliefs link any deviation from risk management or analytic guidelines to sexual exploitation.

Mental Health Consultation

Doctor-patient or prescription model- the consultant advises the consultee about what is wrong with the targeted third party and what should be done about it. Usually implemented when consultees lack confidence in their own intervention strategies. A mental health professional is a health care practitioner who offers services for the purpose of improving an individual's mental health or to treat mental illness. This broad category includes psychiatrists, clinical psychologists, clinical social workers, psychiatric nurses, mental health counselors as well as many other professionals. These professionals often deal with the same illnesses, disorders, conditions, and issues; however their scope of practice differs

Tarasoff decision/Duty to warn

Duty to warn refers to the responsibility of a counselor or therapist to inform third parties or authorities if a client poses a threat to himself or herself or to another identifiable individual. Legal duty to warn was established in the case of Tarasoff v. Regents of the University of California (1976, where a therapist failed to inform a young woman and her parents of specific death threats made by a client. The young woman was subsequently killed and her family sued the therapy provider.

Lethality assessment

Ethical and responsible management of dangerous and suicidal family members is also an important are of liability. Establish positive relationship Understanding and clarifying the problem Various methodologies, tests and assessments to measure suicide risks. Clinical evaluation of suicide risks and the lethality of suicide attempts (understand/clarify problem). How detailed is suicide plan Access to gun, pills, etc. Previous attempts Suicide of family member Assess/mobilize coping resources available to person Formulate a plan- a constructive alternative to suicide action (e.g. no suicide contract, follow-up counseling)

Confidentiality

Foundation of safe therapy, prohibited from disclosing confidential communications to any 3rd party unless mandated/permitted by law to do so Advised to err on side of being overly cautious in protecting confidentiality of clients, unless mandated such as reporting child/elder abuse Clients have right to expect communications will be kept within bounds of the professional relationship Ethical responsibility (as well as legally/professionally) to safeguard clients from unauthorized disclosures of information given in professional relationship Privileged communication: legal concept, generally bars the disclosure of confidential communications in a legal proceeding (therapists can refuse to answer questions in court or refuse to produce a client's records in court) If client waives this right, no legal reason to withhold the information Respect for Privacy. Counselors respect their clients right to privacy and avoid illegal and unwarranted disclosures of confidential information. Client Waiver. The right to privacy may be waived by the client or his or her legally recognized representative. Exceptions. The general requirement that counselors keep information confidential does not apply when disclosure is required to prevent clear and imminent danger to the client or others or when legal requirements demand that confidential information be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception. Contagious, Fatal Diseases. A counselor who receives information confirming that a client has a disease commonly known to be both communicable and fatal is justified in disclosing information to an identifiable third party, who by his or her relationship with the client is at a high risk of contracting the disease. Prior to making a disclosure the counselor should ascertain that the client has not already informed the third party about his or her disease and that the client is not intending to inform the third party in the immediate future. Without a client's permission, counselors request to the court that the disclosure not be required due to potential harm to the client or counseling relationship. Minimal Disclosure. When circumstances require the disclosure of confidential information, only essential information is revealed. To the extent possible, clients are informed before confidential information is disclosed. Explanation of Limitations. When counseling is initiated and throughout the counseling process as necessary, counselors inform clients of the limitations of confidentiality and identify foreseeable situations in which confidentiality must be breached. Subordinates. Counselors make every effort to ensure that privacy and confidentiality of clients are maintained by subordinates including employees, supervisees, clerical assistants, and volunteers. Treatment Teams. If client treatment will involve a continued review by a treatment team, the client will be informed of the team's existence and composition.

Parent's rights regarding information on counseling of a minor

General rule in most states: for minors to enter into a counseling relationship, they must have informed parental/guardian consent or for counseling to be court ordered Parents entitled to general information from counselor about child's progression in counseling Parents have the right to object to having their child in counseling Minors always not able to give their own consent Often necessary to involve parents in treatment process for it to be effective Create clear boundary of what information will be shared and what will not Law favors rights of parents over children even w/ethics of privacy/confidentiality

Purpose of professional code of ethics

Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations Guidelines for psychotherapy with lesbian, gay, and bisexual clients Guidelines on multicultural education, training, research, practice, and organizational change for psychologists Record keeping guidelines Guidelines to practice and work with clients

Counselors who have unresolved personal conflicts

Helpers who are the most effective strive to apply the four following principles to assess characteristics and traits that impact their own ability to assist others and may reflect their own level of health and wellness: Become aware of your personal issues Be open to supervision Avoid hiding behind the use of too many tests Consult when presented with an ethical dilemma. Other Personal Characteristics of an Effective Counselor Motives Emotional Responsiveness Sense of Worth & Anxieties Sex-Role Identity and Expectations Values Cultural Bias

Client's gift giving to counselor

Lavish gifts present an ethical problem, yet we can go too far in direction of trying to be ethical and, in doing so, actually damage therapeutic relationship Some therapists include a policy statement on gifts being received Things to consider: Monetary value of gift Clinical implications of accepting/rejecting gift When in therapy process offering of gift occurs Own motivation behind accepting/rejecting client's gift Cultural implications of offering a gift Advance Understanding. Counselors clearly explain to clients, prior to entering the counseling relationship, all financial arrangements related to professional services including the use of collection agencies or legal measures for nonpayment. Establishing Fees. In establishing fees for professional counseling services, counselors consider the financial status of clients and locality. In the event that the established fee structure is inappropriate for a client, assistance is provided in attempting to find comparable services of acceptable cost. Bartering Discouraged. Counselors ordinarily refrain from accepting goods or services from clients in return for counseling services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship. Counselors may participate in bartering only if the relationship is not exploitative, if the client requests it, if a clear written contract is established, and if such arrangements are an accepted practice among professionals in the community. Pro Bono Service. Counselors contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return (pro bono

Working outside the area in which you are trained

Making sure skills and training required to effectively treat clients in a specific area of practice Understand own competence and refer clients to other professionals when working with them is beyond professional training or when personal factors would interfere with productive working relationship 2.01 Boundaries of Competence (a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience. (b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in (c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study. (d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study. (e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm. (f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles

Managed care system & effect on counseling practice

Managed Care is a system of health care that controls cost of services, manages the use of services, and measures the performance of health care providers. There are different types of managed care plans. Two of the most common types are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Most others are hybrids of the two. Since plans are different, it is important for individuals to know the details of their specific plan. Under managed care, physicians, hospitals, and other health care providers are linked contractually into networks. These providers agreed to provide care to members (patients) at fees established by the network. Network providers also agree to abide by other cost control and practice guidelines set by the network. In general, managed care differs from conventional health insurance in some of the following Much less is known about other managed care models, but research shows that HMOs are achieving cost savings. While this is one advantage to managed health care, critics point to disadvantages. Managed care might result in too few services being provided. Most plans restrict a patient's "free choice" of providers. Managed care does not address the issue of access to health care services for those without insurance, or for those living in rural communities where managed care may not be economically feasible ways. The overall impact of managed care remains widely debated. Proponents argue that it has increased efficiency, improved overall standards, and led to a better understanding of the relationship between costs and quality. They argue that there is no consistent, direct correlation between the cost of care and its quality, pointing to a 2002 Juran Institute study which estimated that the "cost of poor quality" caused by overuse, misuse, and waste amounts to 30 percent of all direct health care spending. The emerging practice of evidence-based medicine is being used to determine when lower-cost medicine may in fact be more effective. Critics of managed care argue that "for-profit" managed care has been an unsuccessful health policy, as it has contributed to higher health care costs (25-33% higher overhead at some of the largest HMOs), increased the number of uninsured citizens, driven away health care providers, and applied downward pressure on quality (worse scores on 14 of 14 quality indicators reported to the National Committee for Quality Assurance)

Behavioral Consultation

Mediation model- Consultants act as coordinators. Their main function is to unify the services of a variety of people who are trying to solve a problem. They accomplish this goal by Coordinating the services already being provided or Creating an alternative plan of services that represent a mutually acceptable synthesis of several solutions

Collaborative Consultation

Process consultation or collaboration model Consultants are facilitators of the problem solving process Their main task is to get consultees actively involved in finding solutions to the present difficulties they have with client. Consultees must define their problems clearly, analyze them thoroughly, design workable solutions, and then implement and evaluate their own plans of action.

Malfeasance

Risk of doing harm to client, engaging in actions that will risk hurting client Of course, best to avoid causing client harm (making sure proper training to practice counseling, aware of legalities, etc.) Be aware of areas that neutrality cannot be maintained, and discuss w/client Unlawful action by a public official

Informed consent

The right of clients to be informed about their therapy and to make autonomous decisions pertaining to it Increase chance client will become involved, educated, and willing participant in his/her therapy Define boundaries and clarify nature of therapeutic relationship Give clients adequate/continuous information so they may anticipate what they will be asked to consent to in treatment Clients give consent w/understanding Means of empowering client Can be a way of engaging participation of a client Content of Informed Consent Therapist's role: what therapist will provide a. Therapy orientation b. Anticipated length of treatment c. Recognized techniques/procedures d. therapist availability Voluntary participation Risks associated w/treatment (may not get better/emotionally painful) Confidentiality Limits of confidentiality (abuse/hurting self or others) Fees Insurance reimbursement Credentials Ethics Cancellation Affiliation w/other practitioners Supervisory notification Disputes/complaints 3.10 Informed Consent (a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. (b) For persons who are legally incapable of giving informed consent, psychologists nevertheless (1) provide an appropriate explanation, (2) seek the individual's assent, (3) consider such persons' preferences and best interests, and (4) obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. When consent by a legally authorized person is not permitted or required by law, psychologists take reasonable steps to protect the individual's rights and welfare. (c) When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding. (d) Psychologists appropriately document written or oral consent, permission, and assent.

How to deal with powerful attractions to clients

There is a prevalent and unfounded belief in the 'slippery slope' argument, which claims that boundary crossings inevitably lead to boundary violations. It refers to the idea that failure to adhere to rigid boundaries and an emotionally distant form of therapy will ultimately foster exploitive, harmful and sexual dual relationships (Guthiel & Gabbard, 1993, Pope, 1990). This paranoid approach is based on the 'snowball' dynamic that asserts that giving a simple gift is the precursor of an exploitive business relationship; a therapist's self-disclosure inevitably becomes an unhealthy social relationship; and a non-sexual hug will quickly devolve into a harmful sexual relationship. To allege that self-disclosure, a hug, a home visit, or accepting a gift are likely to lead to sex and harm is, in Lazarus' words "an extreme form of syllogistic reasoning" (1994, p. 257). Intentional boundary crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed and clearly articulated treatment plan which takes into consideration the client's problem, personality, situation, history, culture, etc. and the therapeutic setting and context. Boundary crossings with certain clients, such as those with Borderline Personality Disorders or those who are acutely paranoid are not usually recommended. Effective therapy with such clients often requires well-defined boundaries of time and space and a clearly structured therapeutic environment. Dual relationships, since they always entail boundary crossing, impose the same criteria on the therapist. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness will always be the paramount concern. Boundaries are like fences; they are man-made and are designed to separate. Their function is to "fence in" and "fence out", to include and exclude. Being man-made, they can be constructed or dismantled, heightened or lowered, and made more or less permeable. Psychotherapy boundaries are an inherent part of the therapeutic setting. They have been the focus of psychoanalysts for clinical-transferential reasons. Consumer protection agencies, boards and professional organizations have focused on the boundary issue in order to guard clients from exploitative therapists.