Monday, April 17, 2006

Professional Ethics and the Clinical Psychologist

Ethical issues are always a concern for most psychologists. As the profession has grown, the ethics code has grown from a brief statement to a whole field of study. Professional ethics create tremendous anxiety for clinicians. Let me scratch the surface by citing an article posted by Ken Pope on his web site.

Pope reports the results of a recent survey of American Psychological Association members on ethical dilemmas. The abstract notes:

A random sample of 1,319 members of the American Psychological Association (APA) were asked to describe incidents that they found ethically challenging or troubling. Responses from 679 psychologists described 703 incidents in 23 categories.

As always, the response rate (just under 50%) raises questions about how representative the results are for American clinical psychologists. But the data does show some interesting trends. First, of the 679 responses, 134 reported experiencing no direct experience of ethical dilemmas. Of the remaining responses, 49% fell into three categories: (a) confidentiality, (b) blurred, dual or conflictual relationships, or (c) payment sources, plans, settings, and methods. Let me give you an idea of what psychologists deal with on a regular basis by just touching on pieces of these three areas.

a. Confidentiality. A clinician cannot reveal any information about a client without the client's consent. There are only three exceptions. First, a judge may order a clinician to reveal information over the client's objects. This rarely happens. It may happen when the client is accused of criminal activity and might have disclosed it to the clinician.

Second, the clinician must reveal information to protect a client who is likely to harm the client or others. This happens more frequently. A depressed client calls a clinician and indicates he is suicidal. If the client refuses to go to the hospital voluntarily, the clinician can initiate involuntary commitment procedures.

Finally, clinicians are required to reveal ongoing or recent information to the authorities concerning sexual or physical abuse of minors (and in some cases, the elderly). There is always real concern about balancing the interests of an abusing client against protection of an abused child. While in some cases it's a no-brainer to report, there are other cases where the abuse is suspected or probable, and the clinician must make a judgment call as to whether or not to report. Remember, when you report your client to the authorities, you may be ending your relationship with the client. If you made the wrong call, and the client isn't abusing a child, all you've done is hurt the client. That client will never go back to another therapist after having the police show up at their door.

Confidentiality issues become more complicated when you are treating children from a divorced couple and there is a noncustodial parent, custodial stepparent, and a noncustodial stepparent. Who gets to hear what, and what do I do to protect my client from a parent who might use that information against the other parent? This is one reason why many clinicians have stopped seeing children. There's too much to sort out and too much extra-therapy time required to deal with all those relationships.

b. Dual relationships. If I am seeing a client for therapy, it is my obligation to avoid any other relationship with the client. So, for example, if my client fixes furnaces, I don't hire him to fix mine. Think of how therapy would go if the client does a bad job for me.

The worst example of dual relationships involves clinicians who have sexual relationships with their clients. It's a felony in Pennsylvania, yet it still happens remarkably often. Hollywood seems to think there's nothing wrong with it, which is really bizarre, given the amount of therapy taking place there. There were some recent jokes on TV about it, which really offended me.

Even dating a client years after you have terminated therapy is a terrible idea, although in some instances, it's considered ethical. Personally, I don't see how you can have a relationship with a former client that is truly egalitarian. There would always be some remnant of the old theraputic relationship there.

For those of us in small communities, simple decisions can raise problems with dual relationships. For example, say I want to buy an Accura. The only dealer in town is a client of mine. Do I go to the client's dealership (in which case, he can look at my credit history—another can of worms), or do I go out of town? How do I explain that to my friends, without revealing my relationship to the client, or implying there's something wrong with the dealer? Imagine if that gets back to the client.

c. Payment for services. When clients lose their health insurance or if their benefits run out, the clinician is left in a quandry. Referring long-term clients away to a county agency can be traumatic for the client, evoking old fears of abandonment. When I was in private practice, I might decide to see someone pro bono. That's a lot harder to do when you work for a large corporation with specific ideas about the bottom line.

The flip side of payment issues is productivity. Most employers today expect psychologists to produce a quota of charges for the week. The quota has been rising over the years. A long time ago, the American Psychological Association defined a full time caseload as 20 clients a week. As costs have risen and reimbursement has lagged, caseloads have risen.

Currently, it is expected that you see somewhere in the vicinity of 28 or 30 clients per week. That means that you are seeing at least 6 people per day in a 40 hour week. That is certainly doable, but it's very tiring. The last client of the day may not get the best services. At what point does the large caseload become an ethical issue?

Professional ethics are, by their very nature, a minefield. A middle aged psychologist once remarked to me that her only ambition was to make it through to retirement without getting sued. That's a pretty low level of ambition, particularly because the odds of being sued are pretty low, despite the minefield we have to negotiate every day.

When I started into private practice, malpractice insurance cost $150 a year. Today, it's 10 times that amount. Still, that's not a bad expense, compared to many other professions. Part of the reason, I believe, is that American psychologists have taken ethics seriously. While the APA doesn't have much teeth to it's ethics committee, the state boards of psychology do.

State boards are run by state governments. Most of them have written the APA ethics code into their professional licensure laws. The boards have teeth and they do bite on a regular basis. Most boards can issue reprimands, fine psychologists, limit or even revoke their licenses, depending on the severity of the infraction. I hear a lot of complaints about them from other psychologists, but the Boards keep us on our toes. They've made us more responsive to our clients' needs. Last year, in Pennsylvania, according to the Board of Psychology newsletter, only 11 people were disciplined, so in this state, that's not much of a risk.

State boards are only one kind of landmine. The other is the malpractice suit. This, fortunately, is very rare. I believe (I could be wrong here) that the probability of a clinical psychologist being sued in the course of a lifetime is about 2%. Those are pretty good odds. However, I hear from others who have been sued that it is a terrible experience, as it is when you're disciplined by the board.

Ultimately, ethics are about good practice. Keeping up with the latest literature, maintaining confidences, consulting other clinicians when in doubt, are all ways of providing good treatment and keeping yourself safe from malpractice. You can't be 100% certain of avoiding a suit, but you can keep yourself reasonably safe.

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