By Ofer Zur, Ph.D.
This paper is part of an online course on Ethical Risk Management for 6 CE Credit Hours.
Course fulfills law and ethics requirement in CA and other states.
Guidelines
- Always do whatever it takes to help clients while insuring that you do no harm to them in the process.
- Never exploit a client. Place the client’s interest above your own and avoid situations where there are conflicts of interest.
- Always show respect for your clients, taking care never to humiliate them or assail their dignity.
- Place clients’ welfare above your fear of boards, courts, ethics committees and attorneys. Putting your fear above clinical effectiveness is immoral, unethical and may be illegal.
- Remember – you are not paid to practice defensive medicine or risk management. Your duty is to help clients with the concerns and problems they are paying you to remedy.
- Intervene with your clients according to their problems, concerns, needs, gender, personality, situation, venue, environment and culture.
- Provide a safe and trusting place for healing and growth. Cold, distant, disconnected and punitive relationships do not promote healing and are likely to harm clients.
- Protect and respect the clients’ privacy and confidentiality unless by doing so you would fail to safeguard the client, community, society, etc., from harm or as required by the law.
- Intervene with your clients in a way that is most likely to be clinically effective. Do not intervene according to any graduate school professor or supervisor’s dogma or even your own beloved theoretical orientation. In other words, different problems often require different clinical interventions. Technical eclecticism is often the most helpful approach.
- Be aware of the standard of care in your community. This is often referred to as the usual and customary professional standard practice in the community. It has been described as the qualities and conditions that prevail or should prevail in a particular mental health service. The standard of care is the standard that a reasonable and prudent practitioner follows and is based on community and professional standards.
- Adhere to the following different components or aspects of the standard of care:
- Statutes, such as the child or elder abuse reporting laws.
- Licensing boards’ regulations, such as those on supervision.
- Ethical principles of your professional associations or of the professional association that is most relevant to your practice and/or profession.
- Case law, such as the duty to warn.
- Consensus of the professionals and the community as often articulated in professional literature or continuing education workshops.
- Official guidelines published by professional associations, such as guidelines for child custody, record keeping or forensic evaluations.
- Professional literature regarding recent research findings, new theoretical developments, etc.
- Professional standard practices within certain established theoretical orientations, such as psychoanalytic, humanistic or cognitive behavioral therapy.
- For each client, develop an individualized treatment plan which articulates:
- Presenting problem or the problem(s) you are attending to.
- The objectives of treatment. Developing short, intermediate and long-term goals may be beneficial in some cases.
- Ways to assess the effectiveness of the intervention.
- Make sure to update the treatment plan, as necessary.
- The means employed to achieve these objectives and the theory, research or philosophy that guide you in choosing the intervention.
- Keep good records. Your records are extremely important from clinical, ethical, legal and risk management points of view. Make sure that your records include:
- Informed consents and office policies.
- Initial and updated treatment plans.
- Records of consultations, tests, etc.
- Releases or authorization to release information.
- Important phone conversations, correspondence, emails and faxes to and from clients.
- Details about termination, who initiated it and how was it was carried out.
- HIPAA compliance when applicable.
- Referrals to medication evaluations and other tests and evaluations, other mental health professionals, twelve step or drug and alcohol rehabilitation programs, physicians, dieticians, physical training, smoking cessation programs, attorneys and other resources.
- Consult with experts and educated colleagues for their input and assistance in complex and unusual cases. Choose an expert in the area and topic of the consultation. Differentiate between clinical, ethical and legal concerns and choose your consultants accordingly. Document the consultation in your clinical notes. Of course, it is just as legitimate to seek risk management consultation, as well.
- There are several types of cases or situations that merit our special attention and higher level of cautiousness because historically they have presented challenges to therapists. Some of these types of cases are;
- Child custody
- Repressed memory
- Domestic violence
- Child abuse
- There are several types of clients and Dx that merit our special attention. Some of these are:
- Borderline Personality
- Repressed memory
- Paranoid
- Suicidal and homicidal
- Antisocial
- Drug and Alcohol addiction
- Clients with a history of litigation
- Multiple Personality and other dissociative disorders
- Never have sexual contact or sexual relationships with current clients.
- Be very careful and cautious before entering into sexual relationships with former clients. Seek ethical, clinical and legal advice before entering into such relationships.
- Handle clients’ debts with sensitivity. Be very cautious before resorting to debt collection agencies as it may trigger clients’ complaints to licensing boards.
- Practice within the limits of your expertise and within your scope of practice as determined by your education, supervised training and clinical experience.
- Work collaboratively with other health care providers or other professionals when appropriate.
- Respect and protect clients’ confidentiality, privacy and autonomy unless by doing so you would fail to safeguard the client, community, society, etc., from harm or as required by the law. Obtain releases before releasing information.
- Terminate thoughtfully. Prepare for termination and offer referrals and follow-ups when appropriate. Document clearly: who initiated it, when, the nature of the discussion, and potential referrals. Summarize the whole treatment in the records: what was achieved, to what extent, what was not achieved according to the last treatment plan.
- If the client terminates abruptly against your clinical judgment: Send a polite letter expressing your concerns in a clinically appropriate and sensitive way. Offer to continue therapy or to refer the client to another therapist. Add that you will be willing to help with the transition to another therapist if the client requests it. (Of course, get a written release before you discuss the case with anyone.)
- Follow your state, professional and ethical rules and guidelines about supervision. Remember that you are responsible for the welfare of your supervisees’ clients.
- Collect and document collateral information when appropriate.
- Prevent your own burnout by creating balance in your life. Such balance includes balance between professional work, familial, recreational, communal, political and/or spiritual activities.
- Be thoughtful with boundary crossing, such as home visits and other out-of-office experiences, gifts, bartering, touch, and self-disclosure. Document these interventions and, when appropriate, include them in the treatment plans and ground them in a theoretical orientation.
- Be thoughtful with dual relationships. While many forms of dual relationships are unavoidable, ethical and potentially helpful, therapy never involves sexual or exploitative business relationships. Document all dual relationships; include a statement on dual relationships in the office policies and the informed consent; and, consult on complex cases. Avoid dual relationships that, in your assessment, may result in a decrease in objectivity or clinical judgment.
- Pay attention to vicarious liability, such as renters or co-workers.
- Responding to a Licensing Board Investigation