Are practitioners becoming more ethical?

By Rebecca Clay
The Monitor on Psychology
May 2017, Vol 48, No. 5
Print version: page 50

The results of research presented at APA's 2016 Annual Convention suggest that today's practitioners are less likely to commit such ethical violations as kissing a client, altering diagnoses to meet insurance criteria and treating homosexuality as pathological than their counterparts 30 years ago.

The research, conducted by psychologists Rebecca Schwartz-Mette, PhD, of the University of Maine at Orono and David S. Shen-Miller, PhD, of Bastyr University, replicated a 1987 study by Kenneth Pope, PhD, and colleagues published in the American Psychologist. Schwartz-Mette and Shen-Miller asked 453 practicing psychologists the same 83 questions posed to practitioners three decades ago.

The items included clear ethical violations, such as having sex with a client or supervisee. But they also included behaviors that could reasonably be construed as ethical, such as breaking confidentiality to report child abuse; behaviors that are ambiguous or not specifically prohibited, such as lending money to a client; and even some that don't seem controversial, such as shaking hands with a client. "Interestingly, 75 percent of the items from the Pope study were rated as less ethical in our study, suggesting a more general trend toward conservativism in multiple areas," says Schwartz-Mette.

The article is here.

Zero Suicide in Health Care

Published on Dec 15, 2014

If you ask people what you should do to help a person who may be suicidal, most—if not all—would say that person should be referred to a health care professional or organization. So it may come as a shock to learn that many health care professionals and organizations do not know what to do…or even consider it their responsibility to do anything. In this provocative talk, Dr. Michael Hogan describes how the Zero Suicide approach aims to improve care and outcomes for individuals at risk of suicide in health care systems.

Michael Hogan, PhD, is an independent advisor and consultant with Hogan Health Solutions. He serves on the Executive Committee of the National Action Alliance for Suicide Prevention, a public-private partnership advancing the National Strategy for Suicide Prevention (2012). Dr. Hogan was the Public Sector Co-Lead of the Clinical Care and Intervention Task Force that developed the idea of Zero Suicide; he now co-leads the Zero Suicide Advisory Group which strives to promote suicide prevention as a core component of health care services.

www.zerosuicide.com

Crossing the Line: Daubert, Dual Roles, and the Admissibility of Forensic Mental Health Testimony

Sara Gordon
Cardozo Law Review, Vol. 37, No. 4, 2016

Abstract:    

Psychiatrists and other mental health professionals often testify as forensic experts in civil commitment and criminal competency proceedings. When an individual clinician assumes both a treatment and a forensic role in the context of a single case, however, that clinician forms a dual relationship with the patient — a practice that creates a conflict of interest and violates professional ethical guidelines. The court, the parties, and the patient are all affected by this conflict and the biased testimony that may result from dual relationships. When providing forensic testimony, the mental health professional’s primary duty is to the court, not to the patient, and she has an obligation to give objective and truthful testimony. But this testimony can result in the patient’s detention or punishment, a legal outcome that implicates the mental health professional’s corresponding obligation to “do no harm” to the patient. Moreover, the conflict of interest created by a dual relationship can affect the objectivity and reliability of forensic testimony.

A dual clinical and forensic relationship with a single patient is contrary to quality patient care, and existing clinical and forensic ethical guidelines strongly discourage the practice. Notwithstanding the mental health community’s general consensus about the impropriety of the practice, many courts do not question the mental health professional’s ability to provide forensic testimony for a patient with whom she has a simultaneous clinical relationship. Moreover, some state statutes require or encourage clinicians at state-run facilities to engage in these multiple roles. This Article argues that the inherent conflict created by these dual roles does not provide a reliable basis for forensic mental health testimony under Federal Rule of Evidence 702 and should not be admitted as reliable expert testimony by courts. Because dual relationships are often initiated due to provider shortages and the unavailability of neutral forensic examiners, this Article will also discuss the use of telemedicine as a way to provide forensic evaluations in under served areas, especially those where provider shortages have prompted mental health professionals to engage in dual clinical and forensic roles. Finally, this Article argues that courts should exercise their powers more broadly under Federal Rule of Evidence 706 to appoint neutral and independent mental health experts to conduct forensic evaluations in civil commitment and criminal competency proceedings.

The article is here.

Record-keeping controversies: Ethical, legal, and clinical challenges

By Ken Pope
Canadian Psychology
Vol. 56(3), August 2015, 348-356

Abstract

The growing array of record-keeping laws, ethical standards, and professional guidelines has created controversy and confusion. Clinicians struggle with what to leave in, what to leave out, how to handle records securely, when to respond to requests for records versus when to refuse, and so on. This article focuses on 5 challenging areas: confidentiality; informed consent; the state, the law, and legal requirements; third-parties; and the implications of research findings for record keeping. It discusses published claims, critiques, proposals for change, and research reports, particularly those of Bemister and Dobson (2011, 2012); Castonguay (2013); Christie, Bemister, and Dobson (2014); Furlong (2013); and Mills (2012). It emphasizes the potential problems with any “1 size fits all” approach and the difficulties in creating sensible regulations that do justice to the diversity of values, contexts, cultures, and theoretical orientations.

The entire article is here.

Is Age a Determinant Variable in Forgoing Treatment Decisions at the End of Life?

Guest post by Sandra Martins Pereira, Roeline Pasman and Bregje Onwuteaka-Philipsen
Journal of Medical Ethics Blog
Originally posted May 14, 2015

Decisions to forgo treatment are embedded in clinical, socio-cultural, philosophical, religious, legal and ethical contexts and beliefs, and they cannot be considered as representing good or poor quality care. Particularly for older people, it is sometimes argued that treatment is aggressive, and that there may be a tendency to continue or start treatments in situations where a shift to a focus on quality of life in light of a limited life expectancy might be preferred. Others argue that an attitude of ageism might prevent older people from receiving treatments and care from which they could benefit, thus resulting in some type of harm and compromising the ethical principles of beneficence and non-maleficence.

When the need to make a decision about treatment concerns an older person at the end of life, physicians need to reflect on the following questions: In this situation, for this person, what is the best course of action? Is this person capable of assessing the situation and making a decision about it adequately herself? What are the preferences of the person? Who needs to be involved in the decision-making process? What will be the consequences of starting or withholding this treatment?

The blog post is here.

The paper is here.

Vignette 28: Another Point of View

A psychologist who completes evaluations for the Bureau of Disability Determination (BDD) calls you for a consultation.

Earlier in the day, the psychologist evaluated a 48-year-old male with a history of chronic pain.  The only documentation received from BDD was a list of medications, which included an antidepressant and a prescription sleep aid.

The disability applicant arrived late for the evaluation, reporting that his pain prevented him from being on time.  He shuffled his feet, walked in a hunched manner, used a cane, shifted in his seat frequently, and groaned throughout the evaluation.  He described rather significant cognitive and vegetative symptoms of depression.  He began to cry softly at one point when discussing the negative consequences of chronic pain.  When asked about outpatient psychological treatment, the disability applicant explained he did not know that psychotherapy could help, and he would be anxious to try therapy.

At the end of the evaluation, the patient left, shuffling and making muffled groans as he left the office and the waiting room.  When the psychologist returned to his office, he remembered a lunch date for which he was late.  As he was leaving the office building, the psychologist saw the disability applicant in the parking lot laughing with another person.  He twirled his cane with one hand.  He stood upright and seemed genuinely happy.  When the disability applicant met the psychologist’s gaze, the applicant immediately hunched over, grabbed his back, groaned loudly, and used the cane to steady himself.  The psychologist hopped in his car for lunch without any discussion with the applicant.

Knowing that BDD evaluations are used within a legal context (in that lawyers, other psychologists, and administrative law judges will see this report), the psychologist asks the following questions:

1. What are the psychologist's ethical duties to the BDD?

2. What are the psychologist's ethical duties to the applicant?

3. Is the psychologist permitted to use any of his observations outside of the office as part of his report? If so, why?  If not, why not?

4. If so, should it be included as an addendum or as part of the body of the report?

5. In either case, how do these observations influence the psychologist’s rating of truthfulness or veracity during the evaluation?

6. Does the psychologist have any obligation to clarify what happened in the parking lot with the disability applicant by phone?

7. If not, how should the psychologist respond if the disability applicant calls him to discuss the evaluation or the interaction in the parking lot?

8. Is it appropriate to use the term “malingering” in the report, given that there is such a small sample of behavior?

Clinical Challenges in the Internet Era

By Glen O. Gabbard, M.D.
American Journal of Psychiatry

Here's a central passage from the initial case presentation:

[begin excerpt]

Much to the treatment team's surprise, within a week of Mr. R's first outpatient appointment, Mrs. R had begun posting disparaging comments on various web sites about the quality of her son's care, specifically naming the treating resident.

The comments described the treating resident as well as other members of the treatment team in derogatory terms. 

In addition, Mrs. R made comments that were vehemently antipsychiatry, including a statement that psychiatrists collude with pharmaceutical companies to generate profit rather than treat illness.

She posted multiple comments in the days following certain clinic visits; the comments could be found easily by anyone who did a Google search using the treating resident's name.

The comments initially appeared on both a personal blog and a highly popular web site, later cropping up also on web sites that serve as general forums for consumer dissatisfaction and on news outlets as user-generated content.

(cut) 

Two main concerns arose from the ensuing dialogue. Foremost was the potential for the mother's online comments to undermine Mr. R's care. For example, awareness of his mother's comments could exacerbate Mr. R's paranoia, leading to a disruption in his trusting relationship with the resident and a possible interference with his adherence to treatment. Moreover, the tone of the mother's comments suggested a fundamental disagreement with the treatment team's approach to her son's care, one that could potentially lead to an impasse. In the absence of a satisfactory working relationship with Mr. R's mother, the team would need to consider discharging him with a referral to another provider. Were they to do so, however, apart from feeling disappointed at not being able to continue providing Mr. R's care, the team would risk appearing either to be punishing him for his mother's actions or abandoning him for no clear reason. Either interpretation might fuel the paranoid perceptions he had regarding mental health care providers.

The second concern was that the mother's comments could damage the reputation of the treating resident. The resident initially did not think to be worried about his reputation, since he felt confident that he was well regarded by those who knew him and had observed his work with patients. Once this concern was raised, however, the resident thought of the potential impact the mother's public comments might have if he sought employment or further training outside his current institution. Given the fact that there is only limited public commentary concerning residents, a few negative Internet postings might adversely affect the opinions of potential patients, peers, or employers. Hence, the situation presented a quandary regarding how to respond to the comments posted online by Mr. R's mother while trying to avoid both potential harm to the patient and potential harm to the resident.

 (cut)

 Discussion: 

When I was asked to consult on this case, I felt a good deal of empathy for the resident.

Here he was, delivering good psychiatric care to a young man with severe illness, but receiving criticism rather than appreciation from the family. 

I recognized that there is now a public exposure inherent in psychiatric practice that can be daunting even to experienced clinicians but may be especially painful to vulnerable residents who are striving to become competent psychiatrists. 

[end excerpt]

Here's how the article ends:  

What can we do as a profession in the face of these challenges? The proliferation of Facebook, Internet forums, Twitter, blogs, and chat rooms is a juggernaut that cannot be stopped. We must live with these new intrusions into our professional lives and develop creative solutions. Institutions can develop policies so that ad hoc groups do not have to be assembled whenever delicate situations with potential liability arise.

Psychiatrists and other mental health professionals can do periodic Internet searches of themselves to keep abreast of any personal or professional information about them that may have implications for their reputation. In some cases, web site administrators may be contacted who will remove what is posted. Those who use social networking sites like Facebook should probably use all available privacy settings so that personal information about them is not available to the public.

The education of psychiatric residents and other mental health professionals should include discussions of common challenges that occur in the Internet era so that clinicians have some preparation for dealing with them when they emerge. Finally, guidelines regarding how to continue the treatment and how to respond to the attacks should be developed. Academic psychiatry has a long tradition of establishing protocols to deal constructively with difficult events in the trainee's life, such as patient suicide or assault. Similar forms of support and assistance can be brought to bear to assist with challenges stemming from the Internet."

 Thanks to Ken Pope for this information.

 The entire article is here.

Membership is needed to acces this information.

Gabbard GO. Clinical challenges in the internet era. Am J Psychiatry. 2012

May;169(5):460-3. PubMed PMID: 22549206.