Vignette 35: Initial Telepsychology Session for Free?

Dr. Larry Ellison, a psychologist colleague, contacts you about a marketing plan for his telepsychology services.  He has over 1,000 followers on Twitter and a strong social media presence on Facebook.  His plan is this: He wants to offer one free psychotherapy session to potential patients. He explains he is trying to promote his telepsychology practice and show that psychologists are open, friendly, and willing to help, potentially for free to get treatment started.  The overarching goal is to develop a robust telepsychology practice.

Knowing the rules of his state, Dr. Ellison will make it clear that services are only available in the states that he is licensed.  Dr. Ellison will use a HIPAA-compliant videoconferencing service.  He is looking for general feedback, such as thoughts on a good marketing plan or any ethical concerns.

Upon hearing his plan, do you have any ethical concerns about this marketing plan?

What are some of the practical or potential pitfalls of this plan?

What are some of the overarching ethical principles involved in this decision?

What state laws would you consider to help make this decision?

Later Career Remedial Supervision - The Practice Event Audit

Jon Amundson
The Practitioner Scholar: Journal of Counseling and Professional Psychology 32 
Volume 5, 2016

Abstract

Clinical supervision has for the most part focused upon early career preparation and training. Fundamental to this process is emphasis upon emerging competency. However, supervision can also be required in relation to enduring competency. Where lapses in professional practice are of a subtle or non-egregious nature, supervision may arise as a remedial route. Through hearing, tribunal mandate or negotiation, arising from Alternative Dispute Resolution (ADR), remedial supervision may be the outcome. In this article mandated or negotiated remedial supervision is discussed with a specific description of a means for such – the Practice Event Audit. Issues related to ethics, conduct and competency, remedial supervision and the Professional Event Audit are discussed in light of a case example.

The paper is here.

The Psychology of Whistleblowing

James Dungan, Adam Waytz, Liane Young
Current Opinion in Psychology
doi:10.1016/j.copsyc.2015.07.005

Abstract

Whistleblowing—reporting another person's unethical behavior to a third party—represents an ethical quandary. In some cases whistleblowing appears heroic whereas in other cases it appears reprehensible. This article describes how the decision to blow the whistle rests on the tradeoff that people make between fairness and loyalty. When fairness increases in value, whistleblowing is more likely whereas when loyalty increases in value, whistleblowing is less likely. Furthermore, we describe systematic personal, situational, and cultural factors stemming from the fairness-loyalty tradeoff that drive whistleblowing. Finally, we describe how minimizing this tradeoff and prioritizing constructive dissent can encourage whistleblowing and strengthen collectives.

The entire article is here.

Dilemma 33: Breaking Bad (or Good)

Dr. Jesse Pinkman has been working with a 26-year-old professional for about a year, Ms. Skyler White. They have been working on managing her symptoms of depression and anxiety.  The patient smokes marijuana regularly, which has been a concern for Dr. Pinkman.

Skyler arrives late to her appointment, looking frazzled.  She explained her friend overdosed on heroin the prior evening.  She has been in the ER for the past 12 hours.  Her friend will likely survive, but she may have residual cognitive problems.

Skyler reported feeling horribly guilty because she introduced her friend to her next door neighbor, who is the drug dealer.  Her friend always stops by to see Skyler first, before purchasing drugs. Skyler purchases her marijuana from the same dealer.

After processing the events of the previous evening, Skyler stated she will move away from the drug dealer.  She no longer wants to be this close or indirectly cause harm to someone else.  The police are actively investigating, but Skyler does not want to divulge any information.  She does not want to get involved.  Skyler makes an appointment for next week, and then leaves feeling somewhat better.

Dr. Pinkman becomes preoccupied about what Skyler reported.  Dr. Pinkman knows the dealer’s name from previous sessions and can figure out the address of dealer, based on his patient’s address.

Dr. Pinkman is contemplating calling in an anonymous tip to the police.  Dr. Pinkman is aware of the increase in heroin use in his community.  He also recognizes his struggle with moral outrage and sense of injustice in this situation.  Struggling with the emotions to report or not report anonymously, Dr. Pinkman calls you for a consultation.

What are the competing ethical principles in this situation?

How would you feel if you were Dr. Pinkman?

What are some of the positive and negative consequences about Dr. Pinkman making the anonymous report?

How do your own professional values and personal morals influence how you would respond to Dr. Pinkman?

How would you respond to Dr. Pinkman’s moral outrage?

Would your answers differ if the friend died?

Would your answers differ if the patient was of low socio-economic status?

Would your answers differ if Skyler were a teenager?

Anticipating and Resisting the Temptation to Behave Unethically

Oliver J. Sheldon and Ayelet Fishbach
Published online before print May 22, 2015
doi: 10.1177/0146167215586196

Abstract

Ethical dilemmas pose a self-control conflict between pursuing immediate benefits through behaving dishonestly and pursuing long-term benefits through acts of honesty. Therefore, factors that facilitate self-control for other types of goals (e.g., health and financial) should also promote ethical behavior. Across four studies, we find support for this possibility. Specifically, we find that only under conditions that facilitate conflict identification—including the consideration of several decisions simultaneously (i.e., a broad decision frame) and perceived high connectedness to the future self—does anticipating a temptation to behave dishonestly in advance promote honesty. We demonstrate these interaction patterns between conflict identification and temptation anticipation in negotiation situations (Study 1), lab tasks (Study 2), and ethical dilemmas in the workplace (Studies 3-4). We conclude that identifying a self-control conflict and anticipating a temptation are two necessary preconditions for ethical decision making.

The article story is here.

Deceased clients and their wills

When a treating psychologist receives a bequest, what ethical considerations come into play?

By Stephen Behnke, JD, PhD, MDiv
The Monitor on Psychology
May 2015, Vol 46, No. 5
Print version: page 72

Here is an excerpt:

Most risk managers — people who work for insurance carriers, for example, whose primary goal is to lower a psychologist's exposure to risk — will advise the psychologist to decline the property. This advice makes good sense. The situation invites a claim that the psychologist exercised undue influence over the client, which is a relevant legal standard for overturning the bequest. The likelihood that a claim of undue influence will be made against the psychologist rises exponentially if the client had heirs, or potential beneficiaries of the estate who are found. If a complaint is made to an ethics committee or licensing board, the psychologist will bear the burden of demonstrating that there has been no exploitation:

The entire article is here.

Parents who wish no further treatment for their child

By M.A. de Vos, A.A. Seeber, S.K.M. Gevers, A.P. Bos, F. Gevers, and D.L. Williams
J Med Ethics 2015;41:195-200 doi:10.1136/medethics-2013-101395

Abstract

Background

In the ethical and clinical literature, cases of parents who want treatment for their child to be withdrawn against the views of the medical team have not received much attention. Yet resolution of such conflicts demands much effort of both the medical team and parents.

Objective

To discuss who can best protect a child's interests, which often becomes a central issue, putting considerable pressure on mutual trust and partnership.

Methods

We describe the case of a 3-year-old boy with acquired brain damage due to autoimmune-mediated encephalitis whose parents wanted to stop treatment. By comparing this case with relevant literature, we systematically explored the pros and cons of sharing end-of-life decisions with parents in cases where treatment is considered futile by parents and not (yet) by physicians.

Conclusions

Sharing end-of-life decisions with parents is a more important duty for physicians than protecting parents from guilt or doubt. Moreover, a request from parents on behalf of their child to discontinue treatment is, and should be, hard to over-rule in cases with significant prognostic uncertainty and/or in cases with divergent opinions within the medical team.

The entire article is here.

A Little Girl Died Because Canada Chose Cultural Sensitivity Over Western Medicine

By Jerry Coyne
The New Republic
Originally published

On Monday, Makayla Sault, an 11-year-old from Ontario and member of the Mississauga tribe of the New Credit First Nation, died from acute lymphoblastic leukemia after suffering a stroke the previous day. This would normally not be big news in Canada or the U.S.—except for the fact that Makayla's death was probably preventable and thus unnecessary.

Makayla died not only from leukemia, but from faith—the faith of her parents, who are pastors. They not only inculcated her with Christianity, but, on religious grounds, removed her from chemotherapy to put her in a dubious institute of “alternative medicine” in Florida.

The entire article is here.

School Psychology in Rural Contexts: Ethical, Professional, and Legal Issues

Lynn M. Edwards, Amanda L. Sullivan
Journal of Applied School Psychology 
Vol. 30, Iss. 3, 2014

Abstract

Delivering psychological services in rural communities presents a number of unique challenges for practitioners relative to their peers in urban and suburban communities. In this article, the authors describe the current context of rural schools and examine the ethical and legal issues school psychologists may face when practicing in rural educational settings. They link these issues to the field's ethical guidelines and educational policy and offer practical recommendations for resolving potential dilemmas. Implications for practice, training, and research are discussed.

(cut)

As in any professional context, it is important that rural practitioners engage in ongoing self-reflection of their competence, well-being, and ethical conduct. Our focus was on professional issues for rural practitioners, but these issues apply to small communities generally, including those located within more densely populated locations where similar social dynamics operate (e.g., ethnicity/cultural communities, a lesbian/gay/bisexual/transgender community, universities, or military communities; Schank et al., 2010). For school psychologists practicing outside of schools (e.g., private practice), other ethical issues related to the provision of mental health services and social justice may be more salient than the topics addressed herein (see Bradley, Werth, & Hastings, 2012, for discussion). In general, practicing in tightly bound communities requires recognition and responsiveness to the distinct professional context created by social and geographic parameters in order to ensure the provision of ethical, effective services.

The entire article is here.

Should Pro-Anorexia Sites Be Criminalized?

Italy’s Parliament recently proposed a bill that would criminalize pro-anorexia site authors with a $67,000 fine and up to a year in jail. But health experts say this is a bad idea.

By Carrie Arnold
The Daily Beast
Originally published August 30, 2014

Here is an excerpt:

While Pinterest, Tumblr, and Instagram banned “thinspiration” photos on the basis that they were linked to self-harm, they continue to allow healthy living advice that isn’t necessarily so healthy, extreme diet and exercise hints, and so-called “fitspiration,” which some in the eating disorder community say is thinspiration disguised in workout clothes. Many of the slogans most closely associated with pro-anorexia rhetoric (“Nothing Tastes As Good As Skinny Feels”) are actually from commercial weight loss sites, as are many of the tips the sites share. Although some use pro-anorexia sites to “learn” how to be better at their eating disorder, many of these tips also exist in stories and television shows designed to teach people about the dangers of eating disorders.

The entire article is here.

When Do Doctors Have the Right to Speak?

Room for Debate

The New York Times

Updated August 22, 2014

Here are two great questions to debate in any ethics class, from the New York Times.

Two federal appellate court decisions, one allowing Florida to prevent doctors from discussing gun safety with patients, the other letting California ban “gay-conversion” therapy, raise questions about health professionals’ First Amendment rights.

Do occupational-licensing laws trump the First Amendment? What limits, if any, does the First Amendment impose on government’s ability to restrict advice?

The responses are here.

Here is one response:

As a physician, it is important to remember the guiding principle of medicine: "first, do no harm." Barring physicians from discussing whether or not lethal weapons exist in the home is wrong. It is well understood that the simple presence of a firearm in the home is associated with a greater risk of bodily harm - either to oneself or any children in the home. Asking about weapons is a usual (standard and accepted) practice as part of the screening assessment for depression; since those with easy access to a firearm and who have suicidal thoughts are significantly more likely to harm themselves. Here, the physician's role is simple: protect human life. Contrast this to the ban on "gay-conversion," therapy, which has been scientifically proven to have more harm than benefit to the individual. In both cases, the tenet being upheld here is to "first, do no harm." It is tragically ironic that those who are often supporting both of these causes are one usually crying to "get the government out of my healthcare," yet they seem perfectly willing to impede the practice of good medicine when it is politically expedient. I can only hope that those supporting the "opposite" views from those expressed here will have a caring physician him/herself that will ignore these political debates in order to provide care that is in the best interest of the patient.

Who Is the Client and Who Controls Release of Records in a Forensic Evaluation?

By Bruce Borkosky
Psychological Injury and Law
August 2014
DOI: 10.1007/s12207-014-9199-6

Abstract

Forensic psychologists often refuse to release evaluation records, especially to the evaluee. One justification for this practice is based on the ethical positions that the referral source “is the client” and “controls release of records” (also found in the Specialty Guidelines for Forensic Psychology). To determine whether these ethical positions are shared by the field of forensic mental health, official documents from forensic mental health organizations were used as a proxy for these views. Thirty-four supporting arguments for either position were identified from the literature; it was postulated that official documents would support both positions and utilize supporting arguments. Fifty-four official documents were discovered, and qualitative analysis was used to construct a 17-category model of official views. Neither position was supported by a majority of documents, and few of the supporting arguments were utilized by supportive documents. The positions are unsupported because official documents espouse a wide diversity of views, there are a number of logical flaws in supporting arguments, and even official APA documents hold conflicting views. Ethical arguments are advanced for contrary positions, and the referral-source-control of records release is contrary to law. A more ethical view is that the psychologist may have multiple, possibly conflicting responsibilities to multiple entities; the psychologist’s roles and responsibilities should be clarified with each entity using an informed consent process. Psychologists should release records at the behest of the evaluee, lest they be subject to licensing discipline, Health Insurance Portability and Accountability Act (HIPAA) complaints, and/or civil sanctions. Recommendations are offered for psychologists, future ethics codes and professional practice guidelines, and test security practices.

The entire article is here.

Moral judgement in adolescents: Age differences in applying and justifying three principles of harm

Paul C. Stey, Daniel Lapsley & Mary O. McKeever
European Journal of Developmental Psychology
Volume 10, Issue 2, 2013
DOI:10.1080/17405629.2013.765798

Abstract

This study investigated the application and justification of three principles of harm in a cross-sectional sample of adolescents in order to test recent theories concerning the source of intuitive moral judgements. Participants were 46 early (M age = 14.8 years) and 40 late adolescents (M age = 17.8 years). Participants rated the permissibility of various ethical dilemmas, and provided justifications for their judgements. Results indicated participants aligned their judgements with the three principles of harm, but had difficulty explaining their reasoning. Furthermore, although age groups were consistent in the application of the principles of harm, age differences emerged in their justifications. These differences were partly explained by differences in language ability. Additionally, participants who used emotional language in their justifications demonstrated a characteristically deontological pattern of moral judgement on certain dilemmas. We conclude adolescents in this age range apply the principles of harm but that the ability to explain their judgements is still developing.

The entire article is here.

The Role of and Challenges for Psychologists in Physician Assisted Suicide

Shara M. Johnson, Robert J. Cramer, Mary Alice Conroy, and Brett O. Gardner
Death Studies, 38: 582–588, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0748-1187 print/1091-7683 online
DOI: 10.1080/07481187.2013.820228

Abstract

Physician assisted suicide (PAS) poses complex legal and ethical dilemmas for practicing psychologists. Since the passage of the Oregon Death with Dignity Act in 1997, Montana and Washington have passed similar legislation. Despite the law requiring competence evaluations by medical and psychological professionals, existing psycholegal literature inadequately addresses the role of psychologists in the PAS process. This article reviews legal statutes and analyzes ethical dilemmas psychologists may face if involved. We consider competence both generally and in the context of PAS. Suggestions are made for psychologists completing competence assessments and future directions to improve competence assessments for PAS are provided.

The entire article is here.

Episode 13: Ethics Education and Vignette Analysis (Number 2)

Lucky Episode 13 mirrors Episode 6 in that the content is similar.  In the first half of the program, John speaks with Dr. Donald McAleer, psychologist and ethics educator, and his pre-doctoral intern Reneh Karamians about ethics education in graduate programs and at internship sites.  We sprinkle in personal experience and the Acculturation Model focusing on how students and early career psychologists may think about ethical decision-making.  In the second half, the participants discuss Vignette #5, A Tricky Situation from the "Vignette Warehouse" at the Ethics and Psychology site.  Dr. McAleer and Intern Reneh arrive at different conclusions as to how to handle the vignette, which nicely models that there can be more than one right answer when dealing with ethical dilemmas.

At the end of this podcast, the listener will be able to:

1. Outline two important components in ethics education,
2. Identify the competing ethical principles in the vignette, and,
3. Practice integrating personal values with professional ethics.

Click here to earn one APA-approved CE credit

Find this podcast on iTunes

Or listen directly below



Information on Dr. Don McAleer's Practice and Associated Pre-Doc Internship

Erie Psychological Consortium

Northshore Psychological Associates

Contact Don McAleer, PsyD, ABPP by email

Relevant Resources for this Podcast

Episode 4: Ethical Decision-making Part 1

Episode 5: Ethical Decision-making Part 2

Nonrational Processes in Ethical Decision-making
Mark Rogerson, Michael C. Gottlieb Mitchell M. Handelsman Samuel Knapp  & Jeffrey Younggren

Beauchamp, T.L. & Childress, J.F. (1994). Principles of biomedical ethics ( 4th ed). New York: Oxford University Press.

Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counseling psychology. Counseling Psychologist, 12(3), 43-55.

The Heinz Dilemma Might Reveal That Morality Is Meaningless

By Esther Inglis-Arkell
io9.com
Originally published April 29, 2014

Here is an excerpt:

But if this finding is true, it seems there are bigger problems with morality. What this experiment seems to say is people can take the same situation, and argue the same principles - social roles, the importance of interpersonal relationships, the likelihood of punishment, and pure humanitarian principles - and come to exactly opposite moral conclusions. And they do this for their whole lives. Sure, it's interesting to see that principles evolve over time, but it's more interesting to see that principles - at least the ones confined solely to the human mind - are irrelevant. There is no method or guiding idea that could possibly allow any group of humanity to come to a consensus. Morality, then, is basically chaos. We can start from the same place, and follow the same principles, and end at diametrically opposite ends of a problem, and there's no way to resolve that.

The entire blog post is here.

Editor's note:

I posted this piece to demonstrate that many struggle to understand morality.  First, moral psychology has moved well past Kohlberg.  Psychologists, especially those who study moral psychology, understand the theoretical and research limitations of Kohlberg.  Please listen to podcast Episode 7 to get a flavor of this.

Second, to believe "morality, then, is basically chaos" is also uninformed.  In moral decision-making, individuals can use different principles to generate different conclusions.  This does not indicate that morality is in chaos, rather, it demonstrates how people use different moral systems to judge and respond to moral dilemmas.

Third, a true moral dilemma involves competing principles.  If it is truly a moral dilemma, then there is no "correct" or "right" answer.  A true dilemma shows how an individual is in a moral or ethical bind and there are cognitive and emotional strategies to generate solutions to sometimes impossible problems. Podcasts 5 and 6 demonstrate how psychologists can knit together possible solutions to ethical dilemmas because, in part, they bring their own moral systems, values, and biases to their work.

The podcasts can be found here.

Vignette 30: The Purloined Patient

Dr. Eddy Kessler received a referral from the Office of Vocational Rehabilitation (OVR) to work therapeutically with Enoch Thompson, who suffers with symptoms of a panic disorder.  Dr. Kessler accepted the referral and started to work with Mr. Thompson on his symptoms of panic and anxiety, as these have interfered with Mr. Thompson’s ability to maintain employment.  Treatment started well, with Mr. Thompson developing better cognitive and behavioral skills to manage his anxiety after the initial eight sessions funded by OVR.  With Mr. Thompson’s consent, Dr. Kessler sent a letter to OVR requesting 10 more sessions over the next five months to reinforce the gains made in treatment.  Dr. Kessler viewed Mr. Thompson as moving toward stable employment with ongoing treatment.  As Mr. Thompson was improving, they agreed to meet in two weeks.

Upon his return two weeks later, Mr. Thompson informed Dr. Kessler that he was recently evaluated by his wife’s psychologist, Dr. Gillian Darmody.  As the patient described it, Mr. Thompson took his wife to her therapy session.  Dr. Darmody asked him to join the session.  The outcome of the session was that Dr. Darmody would be able to get Mr. Thompson on Social Security Disability as she “knows how to write psychological reports” in a way that almost guarantees a favorable disability decision.  She also gave him the name of an attorney to represent him.  He also felt positive about the experience as Dr. Darmody agreed to bill his health insurance for the disability evaluation.  He has a meeting scheduled with the attorney in two weeks.  Mr. Thompson also believes that the consultation with the attorney is free, and that the attorney is paid after disability benefits are awarded.

Dr. Kessler inquired as to why he agreed to the disability evaluation if OVR is trying to return him to work.  Mr. Thompson disclosed that the job market is tough, so he wanted a backup plan in case he gets better and cannot find work.  Mr. Thompson stated he disclosed their treatment relationship.  However, Dr. Darmody deemed their treatment relationship to be inconsequential to the disability evaluation.  The session then focused on Mr. Thompson’s ability to manage anxiety via psychological skills.  Dr. Kessler manages his anger sufficiently to get through the session and scheduled Mr. Thompson in two weeks.

After the session, Dr. Kessler phones you for a consultation.  Dr. Kessler is morally outraged at the other psychologist’s behavior, if true.

What are the possible legal and ethical issues involved in this case?

How would you respond to Dr. Kessler’s moral outrage?

How would you explain the issues to Mr. Thompson?

Are these reasons to terminate your treatment with Mr. Thompson?

If you would continue to work with Mr. Thompson would you change your goals?

How would you document this report from Mr. Thompson in your case notes?

Would you withdraw your request for more sessions from OVR?

What are Dr. Kessler’s options?

If you were Dr. Kessler, what would you do and why?

At Issue in 2 Wrenching Cases: What to Do After the Brain Dies

By BENEDICT CAREY and DENISE GRADY
The New York Times
Originally posted January 9, 2014

In one way, the cases are polar opposites: the parents of Jahi McMath in Oakland, Calif., have fought to keep their daughter connected to a ventilator, while the parents and husband of Marlise Muñoz in Fort Worth, Tex., want desperately to turn the machine off. In another way, the cases are identical: both families have been shocked to learn that a loved one was declared brain-dead — and that hospital officials defied the family’s wishes for treatment.

Their wrenching stories raise questions about how brain death is determined, and who has the right to decide how such patients are treated.

The entire story is here.

Prolonging Life: Legal, Ethical, and Social Dilemmas

The Nour Foundation
Exploring Meaning and Commonality in Human Experience




An absolutely fascinating discussion on end of life issues.

Vignette: 29: A Blog Attack

Psychologist Dr. Shermer learns from a colleague that she has been described in very unfavorable terms in a blog posted by an individual who publicly identifies herself as a patient of Dr. Shermer.

Dr. Shermer reviews the blog information.  The author is likely not a current patient.

The blogger insults Dr. Shermer’s appearance, her style of dress, and her office.  In essence, the blogger combines factual and inaccurate information into a well-formed, yet highly erroneous, description about Dr. Shermer’s role in the community and in the legal system.

There are many descriptions of Dr. Shermer that are blatantly false or misleading. Some of the falsehoods on the blog would be serious violations of the Ethics Code.

Upon reviewing the charts of several possible candidates as the offensive blogger, Dr. Shermer believes the blogger to be someone she evaluated in the past for a national security position.  The likely blogger can be emotionally labile and frequently feels a victim of “the system.” Dr. Shermer indicated a number of pathological characteristics in the report.  Dr. Shermer does not make the determination for the security clearance, but serves as a consultant for the government agency.

Dr. Shermer has a presence on social media and fears how her online reputation may be adversely affected by these ongoing blog posts.  She also fears that if she draws too much attention to the blog, then the blogger will gain greater traction.

Dr. Shermer fears the risk that the information could go to a licensing board and result in an investigation.  Although completely unwarranted, an investigation would add unnecessary stress in her life.  There is also a risk that her reputation could be ruined if the former client’s blog posts gain a larger following.

The psychologist wonders how she can take proactive action.

Dr. Shermer considers hiring an attorney.

Dr. Shermer also considers hiring an online reputation management company.

Dr. Shermer calls you for a consultation.  What are some recommendations that you would make to Dr. Shermer?

How would you feel if you were Dr. Shermer?