Ethics, Fall 2009



Test Your Ethical Knowledge: How Well Do You Know the Ethics Code

October 26, 2017

Eden Resort, Lancaster, PA

Presenter: Rachael Baturin, MPH, JD

Director of Legal and Regulatory Affairs

Modified Bloom’s Educational Taxonomy

|Level |Definition |Example |

|Knowledge |Being able to recite a definition or give a |Psychologists must obtain the informed consent of patients before giving |

| |fact |therapy (some exceptions). |

|Comprehension |Understanding the definition, concept, or |The purpose of informed consent is to secure the permission of the patient|

| |fact. |to start treatment after the patient has been given information that is |

| | |likely to influence their decision to participate in therapy. |

|Application |Being able to apply a concept in actual |Knowing what informed consent processes mean and being able to walk a |

| |practice. |patient through the informed consent process. |

|Analysis/Synthesis |Understanding the component parts of a |Informed consent, at least according to the APA Ethics Code requires |

| |concept and where it fits together with |informing patients of the nature and anticipated course of therapy, fees, |

| |other parts of the concept. |involvement of third parties, and limits of confidentiality and to provide|

| | |patients with the opportunities to ask questions. Informed consent is one |

| | |of many processes in the therapeutic relationship that is designed to |

| | |build trust and to set up parameters likely to ensure the success of |

| | |treatment |

|Evaluation |What is your opinion of the fact or concept?|Informed consent processes further the overarching goal of showing respect|

| |How does it fit into your value system? |for patient autonomy. |

|Creativity |How can you build upon the concept or apply |Are there other ways to promote respect for patient autonomy? |

| |it in unique ways or unique circumstances | |

Anderson et al. (2000). Taxonomy for learning, teaching, and assessing. Boston: Allyn & Bacon.

To be at the “top of your game” ethically you need to know: (1) content of laws/regulations/standards governing the practice of psychology, (2) an ethical decision making model; (3) self-care/self-regulation and self-reflection; (4) protective “habits of practice” and good judgment.

Common Questions (e.g., continuing education, subpoenas, length of time to keep records)

1. Which is TRUE about mandatory continuing education?[1]

a. Psychologists must receive 30 contact hours of CE every renewal period

b. Psychologists can count CE programs from organizations approved as APA or AMA providers of CE

c. Under some circumstances psychologists can use writing or teaching as CE to fulfill CE requirements

d. All of the above

2. Psychologists must turn over records in response to a subpoena[2]

TRUE FALSE

3. Dr. Elizabeth Bennett received a document demanding the release of her records. It was signed by a judge. That document was most likely

a. A subpoena b. a court order

4. Dr. Dora Copperfield wants to get rid of old files. According to the State Board of Psychology, she may destroy all files if it has been ___ years since the last patient contact.

5. Which of the following are NOT true? Psychologists must

a. keep records for at least 5 years after the last patient contact

b. retain the basis upon which test results were obtained for at least 5 years since the last patient contact

c. make plans for the disposition of the records in the case of their death or disability

d. give copies of test materials to anyone who requests, assuming a subpoena or a valid release from a patient

6. The facts that trigger action under the Emerich decision include:[3]

a. patient has an identifiable victim

b. patient poses a threat of “imminent harm”

c. mental health professional concludes, on the basis of their professional judgment, that a third person is in danger

d. all of the above occur

7. Pennsylvania law requires psychologists to give patients a copy of their records.

TRUE FALSE SOMETIMES

8. The term test materials refers to

a. Patient responses to test stimuli b. Copyrighted tests

c. The APA Code of Conduct d. All of the above

9. Psychologists may turn over test materials to anyone assuming a valid release of information has been received

TRUE FALSE

10. Under the Mental Health Procedures Act, any individual who has a serious mental illness may be hospitalized involuntarily if they have

a. Attempted to substantially harm themselves within the last 30 days

b. Attempted to substantially harmed others within the last 30 days

c. Mutilated themselves in the last 30 days

d. Any of the above

11. Dr. Artful Dodger has a patient who is not improving and is unlikely to improve, but who wants to continue treatment. The legal standard is that Dr. Dodger may:[4]

a. Not terminate the patient without his or her consent

b. Terminate the patient without his or her consent if clinically indicated to do so

c. Terminate the patient without his or her consent, if the “three month” rule is followed

d. Not terminate unless the consultation of a psychiatrist is sought

12. The APA ethics codes state that multiple relationships are always unethical.

TRUE FALSE

13. The State Board of Psychology, through regulation, requires all psychologists to adhere to the standards of the American Psychological Association.

TRUE FALSE

14. Psychologists may release confidential information if

a. they receive a court order

b. the patient has signed a release (or authorization)

c. they are mandated by law (such as a child abuse reporting law) to do so

d. all of the above

15. Supervision is the same as consultation TRUE FALSE

16. The State Board of Psychology can deny a license to an applicant who has poor moral character

TRUE FALSE

17. The Standards of the APA Ethics Code apply to all psychological services including telehealth services

TRUE FALSE

18. The records of school psychologists working in the schools and the records of college counseling centers are governed by FERPA and state laws

TRUE FALSE

19. Under HIPAA, state laws that are more protective of patient privacy, from the standpoint of the patient, trump federal law.

TRUE FALSE

20. Even without a release from a patient, psychologists may discuss a case if it is done with consultants for professional purposes, and without an undue invasion of privacy.

TRUE FALSE

More Difficult Questions

21. In Pennsylvania, psychologists must immediately warn an actual or intended sexual partner if their HIV positive patient intends to have sexual relationships with them (if the HIV infected patient has not informed their sexual partner of their serostatus).

TRUE FALSE

22. In Pennsylvania, the executor of an estate can demand and receive the psychological records of a deceased patient.

TRUE FALSE

23. Psychologists in Pennsylvania are mandated reporters of

suspected child abuse b. medical errors (if working in a hospital)

impaired drivers d. all of the above

24. Children who are 14 years old or older and who seek treatment voluntarily have the same control over confidentiality as adults (except for child abuse reporting laws).

TRUE FALSE

25. Estelle Havisham, a troubled 16 year old with narcissistic personality disorder, is receiving treatment upon the consent of her parents. Even without her consent information about her treatment may be sent to:

primary care provider (with parents consent)

another current mental health professional (with parents consent)

to her parents, at least to the extent necessary for them to make an informed decision about treatment

all of the above

26. In Pennsylvania children of any age may seek treatment on their own without parental consent if

a. There is an emergency b. They are emancipated

c. They are married d. All of the above

27. In Pennsylvania a child of any age can seek treatment from a licensed drug and alcohol facility without parental consent.

TRUE FALSE

28. In the Grossman decision, a psychologist was disciplined for

a. Treating a child without the consent of both parents when there was a court order of joint legal custody

b. Evaluating a child for the purposes of developing a treatment plan without the consent of both parents when there was a court order of joint legal custody

c. Conducting a child custody evaluation without the consent of both parents when there was a court order of joint legal custody

d. None of the above

29. When receiving a referral from Children and Youth it is prudent to

a. assume that the representative of Children and Youth always has the legal authority to consent to treatment

b. assume that the representative of Children and Youth has the legal authority to consent to an evaluation, but not necessarily to treatment

c. verify the legal authority of Children and Youth by learning of the contents of the court order specific for this child

d. None of the above

30. A child represents her age as 15 and seeks treatment from a psychologist. For clinical reasons it appeared inappropriate to involve the parents in treatment. The psychologist documented the reported age of the child and her capacity to give informed consent. Later, the psychologist learns that she was only 13 when she initiated treatment. According to the minors consent to treatment law, the psychologist is

a. Legally liable for treating a minor without parental consent

b. Legally liable only if the parents had joint legal custody as specified in a court order

c. Not liable for misrepresentations on the part of the child

d. None of the above

31. When faced with a difficult ethical question, it is best to call the State Board of Psychology and ask them what to do because they are obligated to help psychologists work through difficult ethical questions.

TRUE FALSE

32. Dr. Pickwick wants to stop treatment with a patient. Which one of these situations would constitute abandonment?

a. He packed his schedule so full that he could not schedule a patient for two weeks despite the fact that the patient claimed it was a life-endangering emergency

b. his patient quit treatment; did not respond to a follow up letter offering more appointments

c. he terminated the patient who no longer needed treatment

d. all of the above constitute abandonment

33. According to the APA Ethics Code, test materials are the same as test data.

TRUE FALSE

34. Psychologists always have to use the most recent version of a psychological test.

TRUE FALSE

35. Dr. Copperfield wanted to send the confidential information on his patient (Mr. Barkus) to his primary care physician. Dr. Copperfield asked Mr. Barkus,if he would be willing to consent to the release and Mr. Barkus stated, “Barkus is willing.” Based on this verbal assent, may Dr. Copperfield send the confidential information to the primary care physician?

YES NO

36. The ethics code of psychologists allow them to share information on patients without their consent if

a. classroom materials adequately disguise the identity of the persons involved

b. the psychologist follows the "best interest" rule

c. a family member wants the information

d. a patient threatens serious property damage

37. Under the Mental Health Procedures Act, any person who has an involuntary hospitalization under section 303 of the Act has the right to

a. An informal hearing before a judge (or master) b. An attorney to represent them

c. the right to hear the evidence against them and ask questions d. All of the above

38. Psychologists are required to report impaired psychologists to the licensing board unless

the impaired psychologist is getting treatment

the information were obtained as part of a treatment relationship

the psychologists is treating the psychologists who is apparently impaired

all of the above

39. the reporting of elder abuse is mandated for psychologists who work in

a. solo practices b. privately owned group practices

b. long term care facilities for older adults d. all of the above

40. The record keeping regulations of the State Board of Psychology require psychologists to include

a. custody arrangements for minor children b. the nature and substance of all treatment contacts

b. copies of all patient authorizations d. all of the above

More Difficult, Applications, and Use of Professional Judgment[5]

41. Which of the following is true about safety contracts for suicidal patients?

a. Safety agreements are a good risk management procedure because courts tend to give high deference to the presence of a safety agreement, regardless of how it fits into the overall treatment of the patient.

b. Evidence shows that they help prevent suicides

c. Suicide experts believe that their use is the standard of care for suicidal patients

d. None of the above

42. Dr. Copperfield was named in a court order that he was supposed to provide family education for a particular family. Before accepting this court assignment, Dr. Copperfield needs to

a. do whatever the court says, because he cannot disobey a court order

b. clarify with the court what it means by “family education”

c. at least attempt mediation with the family before engaging in family education

d. all of the above

43. You are reviewing the psychological testing of another psychologist. If done correctly, that psychologist should

a. Identify the bases of all of the substantive conclusions

b. Use the latest version of the psychological test or explain why the latest version was not used

c. Clearly identify if he or she used the results of any previous psychological tests

d. All of the above

44. After going through the informed consent process with a new patient, he blurts out that he intends to kill the man who is having an affair with his wife. Upon hearing this you should

a. try to learn more about the seriousness of the threat

b. discern if he has the means or opportunity to implement this threat

c. develop a relationship with the patient

d. All of the above (a, b, and c)

e. Immediately warn the intended victim

45. When treating suicidal patients it is best to keep as few notes as possible because any clever attorney can take your notes and use them against you.

TRUE FALSE

46. The most common source of licensing board complaints against psychologists, nationwide, is for

a. Boundary violations b. Breaches of confidentiality

b. Wrongful termination d. Failure to get required CE

47. You receive a phone call from an attorney who states that she has just sent you a subpoena and expects you to appear in court in two weeks and that the failure to comply with the subpoena will result in contempt of court and she will ensure that any non compliance will result in your being prosecuted “to the full extent of the law.” You should

a. Immediately agree to appear in court

b. Follow the rules concerning the proper release of patient information

c. Send a notarized letter affirming your receipt of the phone call and agreement to appear in court

d. All of the above

48. John Doe claims that a licensed psychologist breached confidentiality without the authorization to do so, but he was unable to prove that he was harmed by the action. John Doe’s best recourse is a:

a. Licensing board complaint b. Malpractice suit

c. A lawsuit based on “undue influence” d. He has no recourse

49. The State Board of Psychology Code of Ethics applies to

a. licensed psychologists in Pennsylvania b. psychology residents and interns

c. psychology students d. all of the above

50. As agencies of the state, licensing boards must afford psychologists the same due process rights that criminals are guaranteed under the 14th Amendment to the US Constitution.

TRUE FALSE

Ethical Principles

51. The function of the aspirational (General) principles of the APA Ethics Code are to:

a. Guide and inspire psychologists

b. Form the basis for imposing sanctions on psychologists

c. Identify the minimal obligations of psychologists

d. All of the above

52. Which of the following are NOT one of the aspirational principles of APA?

a. Beneficence/nonmaleficence b. Integrity

b. Professional relationships d. Justice

53. Which of the following represent high standards of professional practice? Psychologists should

a. ways get suicidal patients to sign a safety contract

b. keep minimal notes with dangerous patients because any clever attorney can twist your notes around

c. the best risk management advice is to never touch (other than a handshake) or self-disclose to a patient

d. none of the above

54. According to principle-based ethics (the basis of the aspirational principles of the APA Ethics Code)

a. nonmaleficence trumps all other principles

b. justice trumps all other ethical principles

c. no one ethical principle is always given priority

d. none of the above

Values

55.-57. Rank the top three in terms of which you believe they are essential to being an effective psychologist. The most important quality would be ranked as #1.

___ Shows good judgment ___ Compassionate

___ Sense of social justice ___ Conscientious

___ Technically proficient ___ Polite

___ Has an engaging personality ___ Self-reflective

___ Has been able to work out emotional problems of their own

___ Intelligent

58-60. It is common for people (including psychologists) to show self-bias, or to overestimate themselves in terms of intelligence, popularity, looks, technical skill, etc. this has been called the “better than average” effect. Although a certain amount of self-bias may be harmless (or maybe even helpful), problems can occur if the self-bias causes people to ignore constructive feedback, dismiss personal failures, or otherwise refuse to evaluate their behaviors in a somewhat objective fashion. Indeed, one study of physicians found that some of the worst performing physicians rated themselves as well above average.

Identify three ways that you have been (or could be able to) reduce self bias in yourselves or others?

58. _________

59. _________

60. _________

Vignettes: Read each of the vignettes below. Ask what laws (standards of the ethics code) should guide your response to these situations? What are the ethical principals involved? (A list of overarching ethical principles is provided below). How an you maximize adherence to ethical principals in the context of following the law?

Respect for patient autonomy: respecting the decision-making capacities of autonomous persons.

EXAMPLE: respecting the wishes of the patient as to the goals of therapy.

Nonmaleficence: avoiding the causation of harm

EXAMPLE: not using a therapy technique that has a background of unwanted side effects

Beneficence: providing benefits and balancing benefits, risks, and costs

EXAMPLE: selecting the best treatments for the patient.

Fidelity: loyalty to the patient; following through with promises to the patient; placing the patients interest first.

EXAMPLE: avoiding taking patients when a possible conflict of interest could compromise effectiveness of therapy.

Justice: people are treated fairly.

EXAMPLE: fair treatment of all persons regardless of age, sex, race, national background, sexual orientation, socioeconomic status, etc.

General (Public) Beneficence: Concern for the welfare of society.

EXAMPLE: a psychologist takes great care to ensure that the information she wrote in an article to the local newspaper was accurate and up to date.

CASES

Does Emerich Apply?

A patient was assaulted at a party and had to be treated in the emergency room of the local hospital. At her next appointment she informs you that her boyfriend intends to kill the man whom she identified as her assailant. You have not seen the boyfriend in therapy to make your own assessment, but your client tends to be accurate and responsible in her descriptions of things.

Past Crime

You are seeing a 16 year old patient in therapy who confessed that he was playing with matches and accidentally started a fire that resulted in the loss of much property, although no loss of life. He expresses guilt at what he had done and does not appear to be at risk to repeat the offense.

Does Emerich Apply II?

You receive a phone call from your patient asking you to contact the police to confirm that he was threatened by his spouse during your last therapy session. Although there were harsh words in the session, you had a clear impression that the wife’s comment about “blowing his head off” was rhetorical and you believed that there was absolutely no danger to your patient.

Teenage Driver

In your independent practice, you are seeing an adolescent girl who is an honor student. During the course of therapy, you learn that the girl has been smoking marijuana while driving the family car. She often drives her friend’s home after sporting events at school. She narrowly averted an accident yesterday, but intends to keep smoking while driving because (it calms me down.(

Unprofessional Behavior

You have been treating a young woman for several months. Although she seems motivated for treatment, she does not seem to be making any progress. During an especially frustrating session, she reveals that she had been involved in a sexual relationship with her former therapist. Although this client admitted that she was devastated when the relationship ended, she still cares for her former therapist. She will not give you consent to discuss this information with anyone and said she would feel terrible if anything bad happened to her former therapist because she revealed this information.

It’s a Crime

A patient reveals to you that the man convicted of assaulting her is innocent (it was another man who did it). But she isn’t going to tell anyone because she knows the convicted man and doesn’t like him very much. What are you going to do with this information?[6]

Resources

APA Ethics Code, especially Standard 3.05 (Boundaries).

Baturin, R.,, Knapp, S., & Tepper, A. (2005 August). Confidentiality and release of treatment records following the death of a client. The Pennsylvania Psychologist, 4, 7.

Baturin, R., Tepper, A., & Knapp, S. (2003 August). Practical considerations when responding to subpoenas and court orders. The Pennsylvania Psychologist, 5, 16.

Knapp, S. (1998 March). State Board of Psychology revises continuing education regulations: Definition of approved continuing education greatly expanded. The Pennsylvania Psychologist, 1, 3.

Knapp, S. (1998 September). The powers and limitations of the State Board of Psychology, The Pennsylvania Psychologist, 3.

Knapp, S. (2002 May). An overview of HIPAA. The Pennsylvania Psychologist, 11, 21.

Knapp, S. (2002 May). Good treatment can obviate concerns about warning with HIV-positive patients. The Pennsylvania Psychologist, 7, 10.

Knapp, S. (2011 February). The moral character of psychologists: What standards are required for licensees? The Pennsylvania Psychologist, 3-4.

Knapp, S., & Baturin, R. (2009 October). Practical issues regarding professional records. The Pennsylvania Psychologist, 3-4.

Knapp, S., Baturin, R., & Tepper, A. (2010 March). Release of a minor(s voluntary outpatient mental health treatment records. The Pennsylvania Psychologist, 4-5.

Knapp, S., Baturin, R., & Tepper, A. (2010 December). Review of mandated reporting laws and permitted disclosures of patient information. The Pennsylvania Psychologist, 5-7.

Knapp, S., Baturin, R., & Tepper, A. (2011 March). Pennsylvania release of information form. The Pennsylvania Psychologist, 4, 5, 8.

Knapp, S., Baturin, R., & Tepper, A. (2012 December). Questions and answers about parental consent and treatment of minors. The Pennsylvania Psychologist, 4-5.

Knapp, S., Tepper, A., VandeCreek, L., & Baturin, R. (2008). Pennsylvania Law and Psychology, Harrisburg, PA: PPA.

Knapp, S., & Tepper, A. (1996 May). Legal and ethical issues in supervision. The Pennsylvania Psychologist, 18-19.

Knapp, S., & Tepper, A. (2003 May). Termination of treatment of the reluctant patient. The Pennsylvania Psychologist, 5, 19.

Tepper, A., & Knapp, S. (1999 February). Pennsylvania recognizes an affirmative duty to warn third party victims. The Pennsylvania Psychologist, 8, 29.

49 PA Code 41.57 (record keeping); 41.59 (continuing education); 41.61 (Code of Conduct)

PPA website members only: ; password: 4 digit member number found on latest issue of PA Psychologist; log in: last name, first letter capitalized

Answers

1. D 40. D

2. FALSE 41. D

3. B 42. B

4. Five (5) 43. D

5. D 44. D

6. D 45. FALSE

7. SOMETIMES[7] 46. B

8. B 47. B

9. FALSE 48 A

10. D 49. D

11. B 50. FALSE

12. FALSE 51. D

13. TRIE 52. C

14. D 53. D

15. FALSE 54. C

16. TRUE

17. TRUE

18. TRUE

19. TRUE

20. TRUE

21. FALSE

22. FALSE[8]

23. D

24. TRUE

25. D

26. D

27. TRUE

28. C

29. C

30. C

31. FALSE

32. A

33. FALSE

34. FALSE

35. NO

36. A

37. D

38. D

39. B

What Are High Risk Areas of Practice?

The risk of disciplinary action varies according to gender and association membership.

PPA Membership and Disciplinary Actions by PA State Board of Psychology, 1997-2008

| |Member |Non Member |Total |

|Failure to get CE/ false renewal form |13 |49 |62 |

|Boundary violations |3 |24 |27 |

|All other |18 |33 |51 |

|Total |34 |106 |140 |

Gender, Association Membership and Violations2

| |Male[9] |Female |

|PPA Member |20 |14 |

|Not Member |73 |31 |

APAIT Data: High Risk Patient Characteristics: Cluster B personality disorders (borderline, narcissistic); complex PTSD, DID, background of being abused, or recovered memories of abuse; potentially suicidal or homicidal patients; patients involved in lawsuits

High Risk Situations: potential multiple relationships; child custody cases; evaluations with third party consequences (e.g., testing for employment, fitness for duty); supervision

The types of situations that engender inquiries from psychologists (issues that worry them the most) differ from the types of situations that result in disciplinary actions.

Psychologists Inquiries (APAIT; Harris, 2006)

Clinical Management 22% Confidentiality 19%

Divorce Custody 11% Practice Business 11%

Court involvement (Non-Divorce) 11% Reporting Responsibilities 11%

Complaints 9% Evaluations 6%

Sexual Misconduct 3% (Do not add up to 100% because of rounding)

Clinical management– almost one half involve suicidal patients, others include termination/abandonment, multiple relationships and difficult patients.

Confidentiality, release of records, psychotherapy notes and parent/child treatment

Divorce/Custody- almost one-half deal with information or testimony requests

Court involvement (non-Divorce)– more than half deal with request for information or testimony

Reporting requirement– about 40% deal with child abuse; 20% with duty to warn or protect

Complaints– almost all deal with complaints before licensing boards.

Harris, E. (March 31, 2006). Legal and ethical risk management in professional psychological practice- Sequence I. Pittsburgh, PA.

1. Subpoenas: psychologists may only release patient information when (1) responding to a court order (not a subpoena); (2) with the permission of the patient; or (3) in response to a legal requirement to report (such as child protective services law). A court order is signed by a judge; a subpoena is not. When you receive a subpoena that does not include a release signed by the patient, you must “respond” to the subpoena, although the response involves only acknowledging the subpoena.

Dear Attorney X:

In response to your subpoena of DATE, please be advised that I may only release patient information with a court order or a release signed by the patient (or the patient’s legal guardian).

Sincerely,

Dr. Jane Doe

2. Records: The Pennsylvania State Board of Psychology requires keeping records for five years since the last patient contact. You may have contractual obligations with some insurers that require you to keep them longer. You may also wish to keep the records of some patients longer. For example, children may sue a psychologist up to 2 years after they turn 18. This is unlikely to occur, but it is still theoretically possible. Also, some children with serious and pervasive developmental disorders may have a need for their records if they apply for disability later in their life. Again, there is no legal requirement to keep records longer than five years (absent contractual obligations), although psychologists may wish to do so in some cases. Medicare- part C- 10 years

3. Continuing Education. CE violations account for 45 % of all violations by the State Board of Psychology. Some mistakes: (1) failure to give themselves credit for activities that qualify for CE, such as qualified AMA programs that relate to the practice of psychology (the Board has been reasonable about interpreting this); (2) Failure to consider the option of carry over credits; and (3) failure to remember that not all CE programs qualify (programs must be APA approved; AMA-approved and relating to the practice of psychology; or by an entity that has been approved by the PA State Board of Psychology). Illness or hardship? Write the Board and ask for an extension or some accommodation.

4. Informed Consent for Outpatient Treatment for Minors: According to Pennsylvania’s Act 147, any minor aged 14 or older can consent to treatment on their own. Also, any parent can require a minor to get treatment (until the minor is married or graduates from high school, or is legally emancipated). Before the age of 14, any parent can consent to the treatment of their child, UNLESS there is a court order of joint legal custody, in which case the consent of both parents is required. Anyone can treat any child in an emergency. When the parent of a child cannot be located, the presenter believes it is justifiable to treat the child if an honest attempt was made to contact the absent parent (such as a phone call to the last know phone number or letter to the last known address) and no response.

5. Termination. May be done unilaterally if patient is not in an emergency and unable to pay for services (give referrals) or patient is no longer benefitting from service (or being harmed by service). Try to anticipate terminations—minimize unavoidable terminations. Abandonment refers to the unilateral termination of a patient who needs more treatment. It can be intentional (knew patient needed more service and did not provide it); unintentional (should have known patient needed more service and did not provide it), or de facto- because of scheduling did not make appointments in timely fashion. Referrals—give referrals appropriate to the patient, or have them check with PCP, MCO or other source. Three referrals is a rule of thumb, not an absolute rule

6. Life Endangering. Know how to screen for suicide or aggression. Do not use standardized pre written suicide contracts. If you use no suicide agreements involve patients in their development, focus on patient well-being; not any misguided notion of risk management. Know the duty to warn or protect rule in PA (warn if clinically indicated and other means to diffuse danger have failed). Injury is most likely to occur within the family or among acquaintances (especially romantic triangles). Screen for domestic violence. Know the Child Protective Services Law (physical injury, sexual abuse, neglect, emotional abuse). Report if abuse is suspected.

7. Boundaries/Multiple Relationships. These are the most common source of disciplinary complaints against psychologists. The problem of violations is seldom one of lack of knowledge, but insensitivity to potential problems. The standard for determining if a boundary crossing is unethical is whether it is clinically contraindicated or exploitative. Unavoidable crossings should be handled with concern for the patient’s feelings and well-being. Subtle crossings include intrusive advocacy; psychological voyeurism, friendship.

8. Family Issues. When treating children in high conflict families (undergoing a divorce or challenges to custody), be sensitive to issues surrounding custody and ability to consent to treatment (see # 4 above) and boundaries. If you are a therapist, remain a therapy, not a de facto custody evaluator. You will reduce misunderstandings by having roles specified in writing (you are not to be involved in giving opinions concerning custody), clarifying payment (including payment for non-therapy services, such as contacts with collaterals or other third parties). If you are taking a court referral be sure that you understand what the court wants and also how the court wants information handled (does the court order specify to whom you may or have to release information?).

Competence requires distal (“habits of practice”) and proximal (“judicious”) decisions.

Distal Strategies: refers to ongoing habits of practice that accumulate resources and strengths that reduce the risk of problems and increase resources when problems arise. These include on-going continuing education, self-care, self-regulation (including creating/maintaining an environment that supports or protects your goals), and anticipation of problems.

Proximal strategies: refers to the judicious use of strategies in response to immediate case specific need situations. The strategies include empowered collaboration (informed consent), documentation, consultation, redundant protections.

Four Risk Management Strategies

|Strategy |Salient Moral Principles |Examples or Elaboration |

|Informed consent |Beneficence, nonmaleficence, general |divorcing parents bring their child in for therapy. Be very, very |

| |beneficence, Respect for autonomy |thorough in explaining the difference between therapist and custody |

| | |evaluator and alert the parents to the consequences of any failure to |

| | |respect those differences. Inform them of situations where therapy |

| | |could be helpful or iatrogenic. If you anticipate problems get |

| | |documentation and a patient signature on a form. |

|Documentation |Beneficence, nonmaleficence, general |When dealing with life endangering patients, use the 8th grade algebra |

| |beneficence |teacher model (describe what you did and why you did it). Let your |

| | |decision making be as clear and transparent as possible. Acknowledge |

| | |risks and benefits of options and why you chose the one you did. |

|Consultation |Beneficence, nonmaleficence, general |In any situation consultation can be sought to (1) help you clarify |

| |beneficence |your thoughts; (2) reduce your negative affect; or (3) provide |

| | |information that you do not currently have. |

|redundant protections |Beneficence, nonmaleficence, general |Try to get more than one source of data. For example, when treating a |

| |beneficence |suicidal patient it may be helpful to give brief screening inventories |

|(If applicable) | |before the session as a second source of data on the salience of |

| | |suicidal ideation, or having regular contact with a significant other |

| | |of the patient concerning his or her suicidality. |

When using each of these risk management strategies, the general rule is to be transparent as much as possible in what you are doing. That is, you should be transparent, as much as possible, with patients about your goals and methods of assessment and intervention; with persons from whom you are getting consultation; in your documentation as to what you learned, what you are doing and why you are doing it; and transparent in the reasons for your redundant set of protections.

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[1] The single most common reason for psychologists being disciplined by the State Board of Psychology is for the failure to complete mandatory CE requirements.

[2] The most common question to PPA deals with responses to subpoenas or court orders. The second most common question deals with length of retention for records

[3] Duty to warn or protect cases are infrequent, but they have the potential to have a high impact.

[4] Difficult terminations can be one of the most stressful experiences that psychologists have.

[5] These questions focus more on interpretation and the use of professional judgment.

[6] Modified from a vignette from Dr. Derek Truscott

[7] The laws concerning patient access to records are complex and legal right to access varies according to the location in which services were delivered.

[8] Except for services delivered in hospitals where the executors of patients would have a right to those records.

2 For two psychologists the gender could not be determined. Neither of these were association members.

[9] The influence of gender on disciplinary actions is unclear because gender is confounded with age. That is, older psychologists are more likely to be male.

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