Preventing & Managing Common Ethical Predicaments GERALD P. KOOCHER, PH.D., ABPP DEPAUL UNIVERSITY

Preventing & Managing Common

Ethical Predicaments

GERALD P. KOOCHER, PH.D., ABPP

DEPAUL UNIVERSITY

WWW.ETHICSRESEARCH.COM

-Confidentiality Hazards & Mandated Reporting-Ethical Challenges in the Course of Treatment -Managing urgent situations-Pushing boundaries

TODAY’S AGENDA

© GERALD P. KOOCHER, PH.D., 2014, ALL RIGHTS RESERVED 2

What do you know?Who will you tell?NECESSARY SECRETS

3© GERALD P. KOOCHER, PH.D., 2014, ALL RIGHTS RESERVED

Understanding the subtleties of confidentiality


Values underlying confidentiality

Privacy


Stigma Public fearPublic fear and superstition StereotypesStereotypes associated with violence and dangerousness DiscriminationDiscrimination against mentally ill is prohibited under the ADA of 1990 (PL101-336) and Fair Housing Amendments Act of 1988 (PL100-430), but still…


Trust Fundamental to the therapeutic alliance Effective psychotherapy…depends upon an atmosphere of confidence and trust in which the patient is willing to make frank and complete disclosure…

(Jaffe v. Redmond, 1996)


Privacy Court decisions in regard to procreation, death and dying, and mental health illustrate the significant societal concern for privacy.


Autonomy

Competent individuals’ right to self-determination including the decision to seek, select, or forgo health care.


Can you keep a secret?

•Privacy•A constitutional right

•Confidentiality•A professional standard

•Privilege•A narrow legal protection

Confidentiality source:http://jaffee-redmond.org/


Protective Breaches of Confidentiality

Parens patriae Doctrine

Parentalistic state as the guardian or protector of the incompetent◦ Police powers and confinement may be used to protect

◦ Legislatures have enacted protective mandates


Typical exceptions to confidentiality

Patient consent Other treatment providers Reimbursement Disclosure to patient Disclosures to families Quality control and program evaluation

Research Public health reporting Other statutory reporting mandates

Protection of third parties Disclosures to law enforcement Disclosure in court proceedings


Confidentiality Case Law & Psychotherapy

Tarasoff v Regents of the University of California (1976) Jaffe v. Redmond (1996) Swidler & Berlin and James Hamilton v. United States (1998) [More on this later.]

United States v. Chase (2003)

© GERALD P. KOOCHER, PH.D., 2014, ALL RIGHTS RESERVED13

Discretional Breaches Lawsuits (seek releaseseek release) Ethics complaints (seek releaseseek release) Within institution

◦ Treating colleagues◦ Supervision◦ Utilization review◦ Quality assurance


Duties to Third Parties Obligations to payers

◦ Contractual versus non-contractual◦ Patient’s contract◦ Non-subscriber parties◦ Provider’s contract

Targets of violence◦ Tarasoff and its progeny

◦ Tarasoff v. Regents of University of California, 17 Cal. 3d 425, 551 P. 2d 334, 131 Cal. Rptr. 14. (1976)

◦ Risk assessment◦ Identified target◦ Protective steps


Subpoena’s and Court Orders

What is a subpoena? What is a court order? A subpoena compels a responseresponse. Only a court order can compel a disclosuredisclosure.


When it comes to confidentiality,the therapist knows best?

Dianea Kohl thought she did…


Ithaca therapist refuses to turn over notes, charged with contempt6:02 PM, Jan 18, 2013 |

Dianea Kohl spent more than 25 years as a state-licensed marriage and family therapist without encountering legal troubles. But in 2012, the Ithaca resident faced court battles in two area counties involving what she considers a violation of the sanctity of the therapist-client relationship — a violation she believes could have a chilling effect on other counselors and their clients.

“There are only two exceptions to confidentiality — only if I have knowledge of child abuse, or if someone is actively suicidal or homicidal can I breech confidentiality,” Kohl said.

Kohl first ran into trouble when she was called to testify in Steuben County Family Court regarding a child custody case.


Both the father involved in the dispute and his 3-year-old child had been to court-ordered therapy sessions with Kohl. Christine Valkenburg, the law guardian who represented the child, asked that Kohl provide case notes from those sessions. Instead, Kohl presented a summary to the court.

“The law guardian wanted all of my therapy notes. Why did she want my notes unless she thinks I’m hiding something?” Kohl said. “She could not give a reason why she wanted to see the notes. The law guardian went to the judge, and the judge issued an order. That’s when I got my own lawyer.”

“I refused to give up my notes. My ethics say I am not to do that,” she said. “I take lots of fragmented notes. They would not be helpful to the lawyer.”


Opposing view: Valkenburg didn’t see it that way, and neither did Family Court Judge Joseph Latham who signed a contempt-of-court order against Kohl in February. Thehe next thing Kohl knew, she was under arrest in handcuffs.

“I was arrested June 2. There had been a warrant out since February, so I thought they decided not to do anything,” Kohl said. “I was flabbergasted when a state trooper handcuffed me in broad daylight on Route 13. I was shocked.”

Kohl eventually compromised and gave her notes directly to Latham to review. Kohl had discussed the order with her client and received the judge’s promise that only he would see them and that some text would be redacted.


Required Notifications and Breaches (including HIPAA obligations)

Notify at the outset of the professional relationship.

Include state and federal caveats, but when conflicts exist honor the regulation that affords the greater privacy to the client.

Document receipt of notification by the client.

Understand the TPO exception (Treatment, Payment, and Health Care Operations)◦ Providing, coordinating, and managing health care◦ Administrative, financial, legal, and quality improvement


Basic Components of Release Forms

Under HIPAA regulations (45 C.F.R. §164.508) each consent or release form must at minimum contain: A description of the information to be used/disclosed in a specific and meaningful form; The name or specific identification of the person(s) or class of persons authorized to disclose the information; The name or specific identification of the person(s) or class of persons authorized to receive the information; Description of the purpose or requested use of the information; An expiration date or event related to the purpose of the disclosure; and The signature of the person making the authorization and date of signing. If the signer is acting on behalf of another, the relationship should be indicated.

Certain required statements must also appear on the release form to notify the signer that:◦ They have a general right to revoke the authorization in writing, any exceptions, and the procedure to follow.◦ The care provider or institution may not require the release as a condition of treatment, payment, or eligibility for

benefits.◦ Once released the information could potentially be re-disclosed by the recipient and thus no longer be protected.


Insurance Companies and Other Third Party

Disclosures


Under HIPAA regulations (45 C.F.R. §164.508) each consent or release form must at minimum contain:

A description of the information to be used/disclosed in a specific and meaningful form;

The name or specific identification of the person(s) or class of persons authorized to disclosure the information;

The name or specific identification of the person(s) or class of persons authorized to receive the information;

Description of the purpose or requested use of the information;

An expiration date or event related to the purpose of the disclosure; and

The signature of the person making the authorization and date of signing. If the signer is acting on behalf of another, the relationship should be indicated.

Certain required statements must also appear on the release form to notify the signer that:◦ They have a general right to revoke the authorization in writing, any exceptions, and the procedure to follow.◦ The care provider or institution may not require the release as a condition of treatment, payment, or eligibility for benefits.◦ Once released the information could potentially be re-disclosed by the recipient and thus no longer be protected.

Discussing confidential material with colleagues

Inside or outside the institutional context? Properly sanitized health care information is not protected under HIPAA regulations (45 C.F.R. §164.514). The following identifiers should be removed or altered when preparing material for release or discussion in public statements, teaching, or research:

1.Names2.Geographic subdivisions smaller than a state (although the initial three digits of a zip code may be used)3.Any dates (except years) directly related to an individual4.Telephone, fax, social security, medical record, health plan identification, account, medical device identification, or license numbers

5.E-mail addresses web universal resource locators (URLs), Internet Protocol (IP) addresses6.Biometric identifiers including finger and voice prints7.Full face photographic or comparable images8.Any other unique identifying number, characteristic, or code


When the client is a minor


What secrets will parents allow their children? Contract at outset; but minds can change Long-term issues

◦When grown children access their own childhood records.

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Sharing information about children’s psychotherapy with their parents

Basic concept: therapy has to be safe for all participants and parents need to know info about their children that allows them to fulfill parental responsibilities.

Children should have consensual confidentiality rights. Parents should have regular progress reports. Therapists may breach a child’s confidentiality non-consensually to prevent serious harm, disclosing only info necessary for parents to protect.◦ Clarify meaning of serious harm to avoid confusion.

© GERALD P. KOOCHER, PH.D., 2014, ALL RIGHTS RESERVED

When the client is deceased


The focus of access often revolves around inheritance rights and testamentary capacity.

Legal representative of the client’s estate have authority unless specifically prohibited by state law (HIPAA Privacy Rule)

Release is not required if licensed therapist decides, in the exercise of reasonable professional judgment, that treating an individual as personal representative is not in patient’s best interest (HIPAA Privacy Rule)

Interesting more twists on confidentiality rights of dead people

Middlebrook, D. W. (1991). Anne Sexton: A biography. New York: Vintage Books.◦ Martin Orne, MD, PhD

Swidler & Berlin and James Hamilton v. United States U.S. 97-1192.◦ Opinion by Rehnquist, joined by Stevens, Kennedy, Souter, Ginsburg, and

Breyer, held that notes were protected by attorney-client privilege because both a great body of case law and weighty reasons support the position that attorney-client privilege survives a client's death, even in connection with criminal cases.◦ Opinion cited: Jaffee v. Redmond, 518 U.S. 1, 17-18, 135 L. Ed. 2d 337, 116

S. Ct. 1923 (1996)

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Confidentiality Hazards & Mandated Reporting

Mandated ReportingChild abuse/neglect◦ “Reasonable cause to believe” or “reasonable suspicion”◦ Sexual abuse may require additional actionsAbuse/neglect of dependent persons◦ Elderly

◦ May include financial abuse◦ Disabled

◦ May allow more discretion by practitioner◦ Dangerous Driver (including elders and neurologically impaired)◦ Firearm ID laws (Illinois FOID and NY SAFE acts)


Mandated reports Why: protection of the vulnerable and the practitioner. Who, what, and to whom…

◦ Child abuse◦ Elder abuse◦ Dependent person abuse◦ Others…

◦ Abuse of former client(s) (Minnesota)◦ Unsafe drivers (Pennsylvania)◦ Use of tetrahydrocannabinol or has alcoholic beverages during pregnancy (Minnesota)


Adrian Peterson indicted.

Illinois Firearm Owners Identification Act (430 ILCS 65)

On July 9th 2013, Illinois passed HB 183 (Public Act 098-0063), also known as the Firearm Concealed Carry Act. The Firearm Concealed and Carry Act expands the reporting requirements for healthcare facilities and physicians, clinical psychologists and qualified examiners to include any person that is: adjudicated mentally disabled person; voluntarily admitted to a psychiatric unit; determined to be a "clear and present danger"; and/or determined to be "developmentally disabled/intellectually disabled".

The Illinois FOID Mental Health Reporting System website provides mandated reporters with 24-hour and immediate access to report an individual that is receiving mental health treatment or is determined to be a clear and present danger, developmentally disabled or intellectually disabled.


626.5561, Minnesota Statutes 2007: REPORTING OF PRENATAL EXPOSURE TO CONTROLLED SUBSTANCES---

“A person mandated to report… shall immediately report to the local welfare agency if the person knows or has reason to believe that a woman is pregnant and has used a controlled substance for a nonmedical purpose during the pregnancy, including, but not limited to, tetrahydrocannabinol, or has consumed alcoholic beverages during the pregnancy in any way that is habitual or excessive.

Any person may make a voluntary report if the person knows or has reason to believe that a woman is pregnant and has used….

An oral report shall be made immediately by telephone or otherwise. An oral report made by a person required to report shall be followed within 72 hours, exclusive of weekends and holidays, by a report in writing to the local welfare agency. Any report shall be of sufficient content to identify the pregnant woman, the nature and extent of the use, if known, and the name and address of the reporter.”


Psychologist Accused of Failing to Report Child Abuse

POSTED: 6:35 am EDT April 9, 2009 http://www.theindychannel.com/news

NORTH VERNON, IN -- A psychologist was arrested in his Jennings County office Wednesday on a charge of failing to report child abuse or neglect. Police said Dr. Robert Dailey did not report a case in which a juvenile suspect in a child molestation investigation told him of inappropriately touching another juvenile during an appointment. The juvenile's case went through the juvenile justice system.



Bottom line: know the jurisdictional rules that apply to your practice. Including electronic or remote practice!

You’re helping me, but I hate you!

ETHICAL CHALLENGES IN THE COURSE OF TREATMENT


What are your personal risk factors?

Consider:◦Patient Risk Characteristics◦Situation or Contextual Risk◦Potential Loss or Disciplinary Consequences

Modified by:◦Therapist’s “Personal Toolbox of Skills”


Patient Risk Characteristics

Nature of Problem

History

Diagnosis and Level of Function

Expectations

Therapeutic readiness

Financial Resources Including Insurance Coverage

Litigiousness/court involvement

Social Support Network


High Risk Patients

Patients who organize their internal object world into hated and adored objects

◦Borderline Personality Disorder◦Narcissistic Personality Disorder◦Dissociative Identity Disorder (MPD)◦PTSD (complex)◦Patients who were abused as children or are in abusive relationships


Higher Risk Patients

Potentially suicidal patients◦ Conduct frequent risk assessment utilizing current,

evidence based methods essential Potentially violent patients Patients involved in unrelated lawsuits Patients with recovered memories of abuse


Case Example Ms. Smith, a 45 year old mother of 2, seeks treatment because of distress (including nightmares) related to a chronically ill mentally disabled child.

During session 3 she expresses anxiety about upcoming testimony in a licensing complaint against a former therapist who reportedly made sexually suggestive phone calls to her.

During session 4 she mentions (for the first time) that she is concurrently in psychoanalysis (of ten years duration) and that she once impulsively removed all her clothes in an analytic session. She tells you that you seem to understand her better than anyone she’s ever met and she wants you to be her primary therapist.

Your diagnosis and next steps?


Citation for the “undressing” client:

Geist, Richard A.(2009) 'Empathy, Connectedness, and the Evolution of Boundaries in Self Psychological Treatment', International Journal of Psychoanalytic Self Psychology, 4: 2, 165 — 180. ◦ DOI: 10.1080/15551020902730273◦ URL: http://dx.doi.org/10.1080/15551020902730273


Situational Risk Factors Nature of relationship

◦ Therapeutic alliance Real world consequences Setting

◦ Rural versus urban◦ Solo practice versus institutional practice

Type of service requested◦ CBT◦ Family therapy◦ Forensic Evaluation


Therapist’s personal toolbox of skills

Psychological makeup/personal issues◦Personal and professional stress levels

Training background/qualifications Experience Resources

◦ Consultation◦ Access to other providers◦ Involvement with professional groups


So what should I do?

Know the ethical and legal standards that apply. Pay attention to any applicable practice guidelines. Provide comprehensive informed consent. Conduct a conservative evaluation of your competence with clinical populations and activities:◦ Intellectual competence◦ Technical competence◦ Emotional competence


Prepare for a crisis situation Carry insurance (including licensing board defense coverage). Maintain a roster of people to call for

◦ Legal consultation◦ Ethical consultation◦ Hospitalizing a client◦ Mandatory reporting situations.

Ask every client about risky behaviors during intake. Create and use checklists for clients who may pose risks to themselves or others (more on this later, but such a list will remind you to ask key questions and document that you did so).


Standards of care: the “good enough clinician”

Mistake or “judgment call” error◦ People cannot avoid mistakes

(but a mistake ≠ negligence)

Departure from standard of care◦ Many practitioners would not do it

Gross negligence◦ Extreme departure from usual professional conduct most practitioners

would not do it


Understanding Professional Liability Insurance

Occurrence Policies◦ Pay once, covered “forever”

Claims Made Policies◦ Must keep coverage current

Tail coverage◦ (trailing claims)

Nose coverage ◦ (prior acts)

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2012

2013

2016

2015

2014

Risk acc

umulates ove

r years

of practi

ce.

2015

2016

2017

2018

Risk declines after practice ceases.


Most Common Litigation or Licensing Complaint Triggers

Improper care/evaluation

Child-custody related issues

Credit/billing impropriety

Suicides

Homicides

Sexual abuses - dual relationship/boundary violations

Non-sexual dual relationship/boundary violations

Employment practices


Significant Claims/ New Trends

Boundary Violations Suicide Homicide Dual Relationship Billing – Medicare Investigations Copyright/Trademark Infringement (e.g., website images and

music)

50

Improper treatment

Wrongful death


Some things have not changed

Want to cut your risk of an “adverse incident” by 95%?◦ Don’t engage in sexual with current or former clients

or their relatives.◦ Don’t do anything that someone might mistake for a

“forensic assessment,” without adequate training, informed consent, and thorough data collection.

◦ Don’t switch roles in a professional relationship without well documented consent by all parties.


Avoiding legal (forensic) entanglements


To whom do I owe a duty of care and in what hierarchical sequence?

Society at large?All of the above?


Who gets in trouble and why?

Cluelessness counts


Forensic Traps

Just trying to help a friend, client, etc. The “vacation time referral” Anticipating litigation

◦ (I didn’t see that coming!)

To whom do I owe what duties◦ Collaterals◦ Clients for limited purpose


Money Traps: The unpaid bill

You must obey debtor-creditor laws

You can take a client to court, but remember◦Fee disputes often trigger complaints to licensing boards◦You have an obligation to protect confidentiality to the extent possible (aside from disclosing client status and the debt).

You remain responsible for the actions of those who bill on your behalf or who act as collection agents for you.

Take care to avoid any misrepresentation or potential fraud.


Fraud: an act of intentional deception resulting in harm or injury to another. There are four basic elements to fraud.

3. The recipient of the information is unaware of the intended deception.

4. The recipient of the information is justified in relying on or expecting the truth from the communicator. The resulting injury may include financial, physical, or emotional harm.

1. One party makes representations to another, either knowing the claims are false or ignorant of their truth. This may be done by misrepresentation, deception, concealment, or simply nondisclosure of some key fact.

2. The misrepresenter’s intent is that another will rely on the false representation.


What to Do in Money Matters

Inform clients about fees, billing, collection practices, and other financial contingencies as a routine part of initiating the professional relationship, ideally in written form. Repeat this information later in the relationship as necessary.

Carefully consider the client’s overall ability to afford services early in the relationship and help the client to make a plan for obtaining services that will be both clinically appropriate and financially feasible. Encouraging clients to incur significant debt is not psychotherapeutic. In that regard, therapists should be aware of referral sources in the community.

Consider performing some services at little or no fee as a pro bono service to the public as a routine part of your practice.


What to Watch Out For Pay careful attention to all contractual obligations, understand them, and abide by them. Similarly, therapists should not sign contracts with stipulations that might subsequently place them in ethical jeopardy.

In dealing with MCOs, mental health providers should adhere to the same standards of competence, professionalism, and integrity as in other context. Heightened sensitivity should focus on the potential ethical problems inherent in such service delivery systems in which profit may trump client welfare.

In all debt collection situations, therapists must remain aware of the laws that apply in their jurisdiction and make every effort to behave in a cautious, businesslike fashion. They must avoid using their special position or information gained through their professional role to collect debts from clients.


What Not to Do Avoid relationships involving kickbacks, fee splitting, or payment of commissions for client referrals may be illegal and unethical.

Do not allow any misrepresentation of financial transactions effected in their name by an employee or agent they have designated (including billing and collection agents). They must therefore choose their employees and representatives with care and supervise them closely.

Third-party payers may put pressures on clinicians to meet their needs in ways that do not necessarily hold the rights of individual clients paramount. In such instances, ethical clinicians will act in the best interests of their clients.


Sub-optimal terminations APA Code of Conduct: 10.10 Terminating Therapy

(a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.

(b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.

(c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling


What to Do Discuss the issue with client (if realistic and non-dangerous to do so). Make referrals and allow time to follow through (if realistic and non-dangerous to do so). Document your actions and rationales.


Reporting mandates and challenges

Some mandated reporting may lead to discontinuation of treatment. Managing these situations requires a combination of thoughtfulness and adherence to law.

Clinician who obey regulatory requirements that conflict with ethics codes will generally not face ethical misconduct charges, with the exception of human rights violations carried out under cover of supposed governmental authority.


The challenge of multiple-client therapies

When considering work that involves more than one client in the room the therapist should:◦ Think through the rationale for who will be included (i.e., screening in group treatment, rationales

for collateral engagement, planning rules of engagement and cautions for couple/family work).◦ Who (if anyone) is the primary client.◦ What rules of conduct or expectations apply.◦ What limitations apply (e.g., client for a limited purpose or contacts outside of the group context).◦ What hazards apply (e.g., emotional confrontation in group treatment or break-up of couple)

When more than one person hold “client” status the clinician should:◦ Clarify the duties owed to each person and the limitations on those obligations at the outset.◦ Document having done so.


Multiple Client Therapies and Records Groups

◦ No privilege held in relationship to other group members

Couples◦ What is the couple’s contract?

Families◦ What is the contract?◦ What will parents allow?◦ What about break-ups?


Managing urgent situations


Addressing threats to self or others

All patients should be asked about Aggressive behavior toward others, suicidal ideation, and past attempts◦ Consider asking: “What is the riskiest or most dangerous thing you

have ever done?” during intake evaluations.◦ Ask about any incidents where the client has threatened hurt others,

even when they “did not mean to do so.”◦ Ask directly about thoughts/plans for self harm.

No patient is “too healthy” for these questions


Work with Dangerous Clients Assess

◦ Diagnosis◦ History of violence◦ Demographics◦ Availability of potential victims◦ Access to weapons◦ Substance abuse◦ Stressors


VandeCreek’s Decision Model

High

Low

Weak Strong

Violence Risk

Therapeutic Alliance

• Build rapport• Involve significant

others• Hospitalize

• Intensify therapy • Manage environment

Build Rapport

Shift focus to violence management

Break ConfidentialityBreak Confidentiality


Case Example James Holmes and Lynne Fenton, M.D. A University of Colorado psychiatrist told campus police a month before the Aurora movie theater attack that James Holmes had homicidal thoughts and was a public danger, according to records unsealed April 4, 2013. His trial is expected to begin in December, 2014.

Lynne Fenton, a psychiatrist at the Denver campus, told police that Holmes had also “threatened and harassed her via email/text messages” in June 2012. He is standing trial for the July 20 shooting rampage that killed 12 and injured 70 during a midnight premiere of the latest Batman movie. Soon after the shooting, university police said they had not had any contact with Holmes, a graduate student doing neuroscience research. But a search warrant affidavit released Thursday revealed that an officer had told investigators that Fenton had contacted her to report “his danger to the public due to homicidal statements he had made.”


Potentially Suicidal Patients -4

Selected Demographics of Suicidal Patients◦1.4% of all deaths are suicides◦Adolescents and people over 65 most frequent age groups◦Completion rate = male to female rate 3:1◦Clinical diagnosis and suicide

◦ Over 90% are associated with mental disorder.◦ Patients with a major mental disorder are 10 times more likely to die by suicide.


Potentially Suicidal Patients Suicide is the most frequent mental health emergency

◦ 1 out of 5 psychologists will lose a patient to suicide◦ 1 out of 6.5 psychology trainees◦ 1 out of 2 psychiatrists

Heavy emotional toll on both survivors and clinicians

Frequent cause of malpractice suits◦ 5.4% for psychology and 20% for psychiatry



Diagnoses and suicide◦ Major affective illness = 15% of deaths◦ Schizophrenia = 10%◦ Patients hospitalized for alcoholism = 2-3%◦ Patients with personality disorders (especially

borderline personality) = 8%

Demographics◦ AttemptersAttempters = 10-20 times rate of completers

◦ Mainly female, personality disordered, multiple attempts◦ CompletersCompleters = 50-70% communicate intent in advance,

chiefly to family members and significant others



Standard of Care◦ Clinician is not expected to

predict and prevent suicide.◦ Clinician is expected to

identify elevated risk or suicide and to take reasonable protective and risk reduction steps (where possible).

Assessing Competence in Suicide Emergencies and Treatment◦ Licensed professionals are

expected to be able to handle emergencies.

◦ Practitioners should develop Intervention strategies.

◦ Additional post-graduate training may be required.


Indicators of Suicide Risk History of prior attempts Acute perturbation (e.g., panic attacks and severe insomnia) Incident causing humiliation or shame Hopelessness about future (escape wish) Recent discharge from psychiatric hospital (1 month/1 year) Constriction in ability to see alternatives to current state (escape wish and rigid thinking)

Availability of lethal means Chronic medical disorder with persistent pain History of impulsive, dangerous or self-destructive behavior


Indicators of Suicide Risk Contra indicators to Risk

◦ Dependent children◦ Recognition of the pain that suicide would cause to relatives and friends

◦ Anticipated significant positive events (e.g., wedding or birthday).

Elevated Risk◦ Suicide is a low base rate event.

◦ EveryEvery patient should be asked about present and past suicidal ideation during the initial intake evaluation. No patient is “too healthy” to ask.


Indicators of Suicide RiskAssessment when ideation is present

Information about prior attempts

Patient’s perception of risk and ability to contract for safety

Hopelessness about the future

Available lethal means (including psych Rx)

Availability of working support system

Suggestive behavior (intention to die/survive)

Feelings about hospitalization


Indicators of Suicide RiskAssessment when ideation is present

Psychological testing (e.g., Beck’s Helplessness/hopelessness Scales, MMPI-2)◦ All instruments tend to over-predict.

◦ No test can predict individual cases.

◦ Consider testing especially when therapist is inexperienced or has countertransference issues.

◦ Managed care instruments may be helpful in accessing treatment resources.


Strategies to consider Hospitalization Strengthening the therapeutic alliance

Intensifying treatment Secure weapons Actively manage the patient’s environment

Stepwise breaking of confidentiality

Warning potential victims Additional protective actions.


Advance Preparations for working with suicidal patients

Self-evaluation◦ Personal feelings about suicide◦ Current capacity to deal with suicidal patient

Knowledge of options and resources◦ Civil commitment criteria and procedures◦ Connections to emergency crisis team, if any◦ Connection to inpatient facilities

◦ Relationships with hospital staff◦ Referral process◦ Staff privileges

◦ Psychopharmacology knowledge base


Advance Preparations for working with suicidal patients-2

Develop good relationship with knowledgeable prescribing clinician(s)◦ Insist on medication evaluations.◦ Insist that medication recommendations be followed as a condition of

your continuing to provide therapy.◦ Consult regularly with prescribing clinician about prescriptions.◦ Keep good notes on all of the above.


Informed Consent with Suicidal Patients

Inform patient and family, if appropriate, or responsibility to protect.

Informed consent statement should contain notice to patient that you will break confidentially where appropriate, if necessary to protect.

“If I believe you are at risk of killing yourself as a way of escaping the emotional pain that brought you to see me, from a therapeutic and human perspective, my only treatment goal is to keep you safe and alive. If this is unacceptable to you, then we probably need to get you to another therapist.”


Support Systems and Suicidal Patients

When possible and appropriate involve significant others in the patient’s treatment◦ Pros and cons vary from person to person and time to time.◦ Can family members be therapeutic allies?◦ Especially important to maintain safety between sessions in out-patient

treatment.◦ Consider others such as clergy or friends when family is not available.◦ Document all, even when involvement of others is contraindicated.


Interventions with Suicidal Patient: Safety Contracts

Commonly used technique with potential clinical value

Not very effective risk management strategy without strong alliance

Reliance on contract alone is rarely good practice

Doubtful value when patient is impulsive, substance abuser, or prone to decompensate or disassociate

If psychologist contracts, must be available on 24/7 basis


Interventions with Suicidal Patient: Outpatient Care With Therapeutic Activism.

Maintain regular contact with prescribing physician Sole focus on treatment = safety Remove lethal agents Be alert to sudden changes in behavior

◦ Flights into health or decisions to divest

Consistent involvement of significant others Consider day-treatment or other isolation reducing activities Document, document, document


Record keeping when treating the dangerous (to self or others) patient

Keeping good records is a must. NeverNever alter a record following a critical event. Include discussions with managed care company if there is disagreement about frequency of treatment or hospitalization.◦ Think out loud to representative about whether to appeal

Get records of past treatment, especially hospitalizations. Maintain records per legal requirements (nature and duration).


Getting consultation on dangerous patients

Especially important where hospitalization is rejected by managed care company

Identify consultants before you need them

Use peer consultation group Vicarious liability

Arms-length, formal, paid consultation is the best protection

Explore all contingencies and options

Be sure your supervisees and assistants consult with you


Postvention: after the eventin general

Self care◦ Bereavement reactions:

mourning the patient’s death◦ Safer if done in personal therapy

than in consultation◦ Be careful what you say and to

whom; limit self-recrimination to confidential relationships

Post mortem conferences◦ Becoming a standard practice for

managed care companies and hospitals

◦ Can be helpful for closure◦ Insist on complete confidentiality

protections with written assurance from company or agency attorney.


Postvention: after the eventwith patient’s family

Often an important risk management tool and a helpful thing to do

Important part of therapist’s own coping

At funeral or giving condolences, avoid revealing your status and remain in background

Any substantive interaction with patient’s family should be in private

Avoid doing more than condolences until own feelings worked through

Be aware of confidentiality issues that survive patient’s death


Postvention: after the eventwith patient’s family

Executor/heirs at law may waive privilege.

Good idea to get waiver from family◦ With appropriate waiver therapist

may discuss case in general, but may also withhold details the patient would have wanted kept private.

Do not provide records without valid subpoena.

Demonstrate therapist cared about patient and empathizes with loss.

Any sessions should be supportive and psychoeducational


Postvention: after the eventa session with patient’s family

Focus session on grieving process and its importance:◦If treatment is needed, refer to someone else◦Survivors’ coping may include anger at therapist◦Referral may feel like abandonment


20 Point Checklist to Consider in Assessing Suicide Risk

1. Direct verbal warning?• Direct statements of intent often precede attempts (90 day risk interval).

2. Plan?• Presence of a plan increases risk, especially if detailed, lethal, and feasible

3. Priors?4. Most completed suicides are preceded by a prior attempt. Indirect statements or behaviors?

• Talk about “going away” or what “death would be like,” or giving away prized belongings.

5. Depression?• Clinical depression increases risk x20

6. Hopelessness• Hopelessness and lack of “escape” options increase risk.


7. Intoxication• Substance abuse disinhibition and increased risk.

8. Special clinical populations?• AIDS patients and torture victims

9. Sex• 3:1 male, 5:1 young male, but females make more attempts.

10. Age?• Risk increases over adult life cycle with attempt to success ratio 7:1 under

age 65 and 2:1 over 65.

20 Points to Consider



11. Race/Culture? • In U.S. highest among Native Americans ages 15-24• Reduced inhibition and pre-contemplation time in some cultural groups

12. Religion?• Higher among protestants than Catholics or Jews (in U.S.)

13. Living alone?• Risk lower if not living alone; lower if with spouse; lower if with children

14. Bereavement?• Complex data, but risk generally increased



15. Unemployment = +

16. Health status• Illness and somatic complaints = +

17. Impulsivity = +

18. Rigid thinking = +

19. Stressful events• Excessive undesirable events = +

20. Release from (Ψ) hospital = +


Assessing Elevated Suicidal Risk

Sample Interview Questions:◦ 1. Have you ever thought about hurting yourself or taking your own life?

◦ Tell me about it. (Active follow-up questions)

◦ 2. Have you thought about it recently?◦ Tell me about it.◦ How would you do it?◦ Have you taken any steps to implement plan?◦ How long have you had plan?◦ Are there other ways of resolving your problems?◦ What are they?◦ Have you shared these plans with anyone?


Interventions Engage support systems

◦ Alert treatment team and family (if appropriate)◦ Discuss crisis plans

Initiate or intensify treatment◦ Medication and psychotherapy work best◦ Assure back up support

Focus on fears and rage themes (in therapy) Never ignore the expression of such feelings


Suggested readings on treating suicidal clients

Bongar , B. (2013). The Suicidal Patient: Clinical and Legal Standards of Care (3rd ed). Washington, D.C., American Psychological Association

Jongsma, A. E. (2004). The Suicide and Homicide Risk Assessment & Prevention Treatment Planner

Mack, J. E. (1981). Vivienne: The Life and Suicide of an Adolescent Girl (1981, non-fiction, with Holly Hickler) Boston: Little Brown

Rudd, M.D. (2006). The Assessment And Management of Suicidality. Sarasota, FL: Professional Resource Exchange.

Shea, C. S. (2011). The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Hoboken, NJ: Wiley.

Wingate, L., Joiner, T., Walker, R., Rudd, M.D., & Jobes, D. (2004). Empirically informed approaches to topics in suicide risk assessment. Behavioral Sciences & the Law, 22, 1-15.


Pushing boundariesPROBLEMS BOTH OLD AND NEW


Psychologist accused of sexual assault on a client

http://www.coloradoconnection.com/news/story.aspx?id=844852#.UO2f0HddB8F


COLORADO SPRINGS, COLO. -- A licensed psychologist has been arrested on the charge of Sexual Assault on a Client by a Psychotherapist, according to Colorado Springs Police.

Dr. Janice Husted was arrested on the charge after a police investigation. A young man told police that a sexual relationship developed between him and Husted, his psychologist.

Police said the man was assigned to receive counseling related to his combat deployments during the summer of 2010. The sexual relationship, according to what the victim told police, started in Aug. 2011 and continued until Oct. or Nov. 2011. The man said the psychologist told him on several occasions that they had to be careful to not appear that they were on dates, police said.

Police said the man told the psychologist he did not want to have a secret relationship but she said they couldn't have an open relationship until two years passed. After saying he did not want to wait two years, the psychologist ended the relationship, police said.

Sexual Assault on a Client by a Psychotherapist is a Class 4 Felony.


Barter counseling for bathroom repair (NE Grand Rapids )Reply to: [email protected]: 2008-12-07, 12:09PM EST

•“My husband is a capable and effecive counselor, licensed...but he is not good at home repairs/construction. I will trade his expertise for your time with him as a counselor if you can help us with tub and tile repair and plumbing. We had a termite problem that we fixed but the place needs a new floor and other stuff...if you are struggling with depression or bipolar, he is your man...maybe your spouse, child, etc. He is truly an excellent counselor. We have our own non-profit and give to others without charging so our financial situation is limited, but looking to trade! thanks.”

•Location: NE Grand Rapids PostingID: 948491022


The Ethical Perils of Social Media

The use of social media and Internet search capabilities have let to new forms of instantaneous mass communications that have eroded traditional concepts of privacy, while creating some new ethical challenges.◦ Invisible access to and use of (previously personal) information◦ New forms of communication that can blur personal and professional boundaries◦ Complex data distribution and communication systems that are readily adopted but often

not fully understood by users◦ New venues for naughty behavior (e.g., bullying, cyberstalking, defamation, and voyeurism)


Case Example Help, I’ve been Yelped

Dr. Frank Lee Stunned, an experienced psychotherapist in private practice, thought he’d dealt with almost everything. He’s run a successful small business despite difficulties with third party payers over they years.

A client alerted Dr. Stunned that he’d seen a negative comment about him while scanning Yelp.com for restaurant reviews.

The review posted by “Still in the Dumps,” reported an increase in her depression and anxiety symptoms after months of working with Dr. Stunned, who she described as “insensitive, incompetent, and abusive.” She noted that she’d always felt uncomfortable about the way he seemed focused on her breasts and wanted to warn other women about him.


I’ve been Yelped Dr. Stunned suspects that “Still in the Dumps” is a borderline patient who he had to terminate because of outrageous demands for more contact and noncompliance with treatment. After the difficult termination she’d muttered about getting even.

Dr. Stunned googled himself and the first search item returned is the Yelp review. He’s anxious, dismayed, and furious. He wants to sue Yelp and the client.

Complaints and threats to Yelp won’t help.

Attempting to seek a libel judgment may make things worse.


What can you do? Monitor your web presence.

Use an optimized professional web site and similar publicity to suppress adverse search returns

Hire an attorney to raise defamation claims with the website

Consider contractual prevention strategies

Consider the services or a reputation protection company (e.g., Reputationdefender.com and Medical Justice.com)

Solicit positive reviews from colleagues

Try to ignore them and hope they won influence consumers.


Potential Response Strategies Reactive Response strategies

◦ Respond on the site without breaching confidentiality.◦ Remind readers that there are two sides to every story and that you owe all

clients a duty of confidentiality.◦ Don’t mention any specifics or identifying information about the patient.◦ Develop an active positive branding program and optimized web site you

control.◦ Collect consumer satisfaction data.◦ Don’t make promises you can’t keep.◦ Remember that the Internet is forever


Professional Web Sites:When you control the message

Access to Information◦ Marketing your practice/products◦ Directions to your office◦ Downloads

Access to Documentation Efficient communication Effective promotion of psychologist’s skills, experience, and competencies/specialties.


But beware… Site security Boundary issues Appropriate marketing Blogging challenges File transfer and e-mail confidentiality


Facebook, LinkedIn, Twitter, Instagram, What’s Next?

Security Issues Retention of Files Friends of Friends boundary issues Fan Harassment Stalking PHI Failure to terminate


Do you Need a Friending Policy?Sample per The Trust:

“I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.”


Suggestion on “Following” Policy

“I publish a blog on my website and I post psychology news on Twitter. I have no expectation that you as a client will want to follow my blog or Twitter stream. However, if you use an easily recognizable name on Twitter and I happen to notice that you’ve followed me there, we may briefly discuss it and its potential impact on our working relationship.

My primary concern is your privacy.”


More on Following

“Note that I will not follow you back. I only follow other health professionals on Twitter and I do not follow current or former clients on blogs or Twitter. My reasoning is that I believe casual viewing of clients’ online content outside of the therapy hour can create confusion in regard to whether it’s being done as a part of your treatment or to satisfy my personal curiosity”


What about searching?


Your clients will search for information about you. What (if anything) does our ethics code have to say about using electronic media and search engines to check on clients? Nothing, but ask yourself why and what you would do with the information you find.

Just a few sample options for data collection 123people CriminalSearches Detectivemagic Facebook Familywatchdog Fundrace Google Guidestar Infospace


Intelius

Instantcheckmate

Netronline

NSOPR.gov

Peoplelookup

Pipl

Searchsystems.net

Spock

Spokeo

Vitalrec.com

Wink

Whitepages

Whowhere

Whois

Zabasearch

Zoominfo

Health Insurance Portability and Accountability Act (HIPAA) and ePHI

KENNEDY-KASSENBAUM

ACT OF 1996

AKA: 45 C.F.R.160


Privacy Rule Terminology Protected Health Information (PHI)

◦ Personally identifiable information that is created or received by a health care provider that relates to physical or mental health of an individual

◦ Increasingly, PHI has become electronic in storage and transportation (ePHI)

Health Care◦ Care or services related to the health of an individual…including but not

limited to …preventative, diagnostic, therapeutic …care and counseling, service, assessment or procedure with respect to the physical or mental condition, or functional status, of an individual…”


Privacy Rule Basics:

Psychotherapist-Patient Privacy Protected in 3 ways:◦Minimum Necessary Disclosure ◦State Law Pre-emption◦Special Protection given to “Psychotherapy Notes.”“Psychotherapy Notes.”


Minimum Necessary Disclosure HIPAA requires we limit 3rd party submissions to the minimum information necessary to conduct the activity for which the data were requested.

Applies to information that can be disclosed without patient authorization.

Insurers/MCOs can still require information necessary to establish medical necessity as a condition of coverage.


Psychotherapy Notes

Mental health information is give special protection under the privacy rule. This is accomplished by dividing Mental Health Information into two categories:

◦Protected Health Information (PHI) referred to as the “Clinical Record”

◦Psychotherapy Notes


What goes in the “clinical record?” The following information, if kept, must rest in the Clinical Record

◦ 1. Medication prescription and monitoring◦ 2. Counseling session start and stop times◦ 3. Modalities and frequencies of treatment◦ 4. Results of clinical tests (including raw test data)◦ 5. Summaries of:

◦ a. diagnosis◦ b. functional status◦ c. treatment plan◦ d. symptoms◦ e. prognosis◦ f. progress to date


What are “psychotherapy notes?”

Actual language of rule on psychotherapy records or notes : ◦ “Notes recorded (in any medium) by a health care provider who

is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session and that are separated from the rest of the individuals medical record.”


Psychotherapy notes: The HHS narrative

“The rationale for providing special protection for psychotherapy notes is not only that they contain particularly sensitive information, but also that they are the personal notes of the therapist, intended to help him or her recall the therapy discussion and are of little use or no use to others not involved in the therapy. Information in these notes is not intended to communicate to, or even be seen by, persons other than the therapist….we have limited the definition … to only that information that is kept separate by the provider for his or her own purposes…not to the medical record and other sources of information that would be normally disclosed for [TPO].”


Must we keep “psychotherapy notes?”

No, we are not legally or ethically required to keep psychotherapy notes; they are completely optional. The decision can vary from patient to patient, and from session to session, depending on the facts and circumstances of the case. Many psychologists elect to keep one set of records to minimize complexity.


More on psychotherapy notes Must be kept separately from basic record. Are not a substitute for individual session notes. Cannot be released without patient authorization.

◦ This includes consultations with other providers

Patient authorization cannot be required as a condition of insurance coverage or as part of managed care utilization review requirements.

Cannot include raw test data.


Sample Fines for HIPAA Privacy and Security Violations Parkview Health System, Inc. has agreed to settle potential violations of the HIPAA Privacy Rule with the Department of Health and Human Services (HHS) Office for Civil Rights (OCR). Parkview will pay $800,000 and adopt a corrective action plan to correct deficiencies in its HIPAA compliance program as the result of medical records dumping.

http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/parkview.html Under another DHHS settlement Affinity Health Plan, Inc. will settle potential violations of the HIPAA Privacy and Security Rules for $1,215,780. OCR’s investigation indicated that Affinity impermissibly disclosed the protected health information of up to 344,579 individuals when it returned multiple photocopiers to a leasing agent without erasing the data contained on the copier hard drives. In addition, the investigation revealed that Affinity failed to incorporate the electronic protected health information stored in copier’s hard drives in its analysis of risks and vulnerabilities as required by the Security Rule, and failed to implement policies and procedures when returning the hard drives to its leasing agents.

http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/affinity-agreement.html


The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.

Excluded psychologists and most other non-physician providers from the list of “meaningful users” of electronic health records Not eligible for Medicare and Medicaid incentive payments designed to encourage adoption of expensive complex systems Lobbying in process


Definitions Electronic Health Records (EHR)

◦ Focus on total health of patient across providers

Electronic Medical Records (EMR)◦ Digital clinical charts; not easily shared

Practice Management Software◦ Demographics, scheduling, billing.

Interoperability◦ Ability to exchange and use information

Role segregation◦ An HER function that limits personnel access to need-to-know elements of record (clerk/clinician)


No mandate for small practices (outside hospitals) yet, but when it comes how will access influence what you write?

Multi-practitioner access Patient real-time access HIPAA and HITECH both mandate role segregation Special mental health data segregation to be developed


Key Ethical Challenges Associated with the Patient Protection and Affordable Care ActCOMPETENCE AND INTEGRITY WITH RESPECT SERVICE AN OUTCOME METRICS.

MULTIPLE ROLE CONFLICTS WITH HEALTH CARE SYSTEMS, REGULATORS, AND OTHER PROVIDERS.

CONFIDENTIALITY WITH RESPECT TO INTEROPERABLE RECORDS AND ELECTRONIC SERVICE DELIVERY.


Are you prepared for the Ethical Challenges of ACOs and PCMHs?(Accountable Care Organizations and Patient Centered Medical Homes)

Organizational models for primary care that will improve our health care system (?)


Robocop and mermaid pet a unicorn.

Integrated Inter-professional Care

Understanding the culture of interprofessional health care practice and functioning as a team player.

Working with patients who have medical, mental health, behavioral health, and co-morbid problems in a fast-paced primary care context.

Working with a more diverse (ethnically, socially, and economically) population than ever before.

Ability to document the value added by psychologists’ engagement.


Administrative and Financial Accountability and Autonomy

Are you prepare to:◦ Seek additional

credentials?◦ Board certification

◦ Integrate your practice?◦ Co-locate?◦ Contract?◦ Become an employee?


How will reimbursement systems change? Medicare Medicaid Insurance exchanges Global payment systems

◦ Who takes the risks?◦ Who makes “medical necessity” decisions?

New billing an diagnostic codes◦ Who’s codes rule?


Will the ICD Replace the DSM?New ICD-10 Codes

V97.33XD: Sucked into jet engine, subsequent encounter. Y93.D: Activities involved arts and handcrafts. SW55.41XA: Bitten by pig, initial encounter . W61.62XD: Struck by duck, subsequent encounter. Z63.1: Problems in relationship with in-laws. W220.2XD: Walked into lamppost, subsequent encounter. Y93.D: V91.07XD: Burn due to water-skis on fire, subsequent encounter . W55.29XA: Other contact with cow, subsequent encounter. W22.02XD: V95.43XS: Spacecraft collision injuring occupant. W61.12XA: Struck by macaw, initial encounter. R46.1: Bizarre personal appearance.


Integrated Record Systems:The eMR, ePHI, and e-billing

Do you want to share your psychotherapy records with your proctologist?

How can you avoid accidentally e-mailing sensitive material?

What problems have we seen most commonly documented?


Electronic issues in malpractice claimsCRICO, 2013

In 147 instances electronic health records contributed to “adverse events” affecting patients — half of them designated as serious (12 month period of newly filed malpractice claims 2012 - 2013, in a total pool of around 5,700 cases.◦ Incorrect information (inserted and/or repeated)◦ Hybrid record conversion problems◦ Electronic routing failures◦ Unable to access data◦ Pre-filled forms or copied and pasted text◦ System design not aligned with need


Steps to take now…

Seek opportunities to learn interprofessional practice skills, new diagnostic and procedure codes.

Gain competence in work with medical patients, particularly with behavioral health and co-morbidity linked to depression and anxiety.

Consider board certification and inter-jurisdictional practice credentials.


More steps to take now… Modify your HIPAA notice (if necessary) to comply with any eMR standards. Educate your patients even if not required under the “TPO exemption.”

Take precautions (and educate your staff) to avoid improper transmissions.

Use strong passwords and consider encryption for your files.

If you consider joining an PCMH use an sophisticated attorney to review the contract and consider an information technology consultant if record integration is involved..


Cloud Computing Where’s the cloud?

How robust is the cloud?

What’s in the cloud?◦ Software◦ Data storage

Who has access to the cloud?

Accessing remote computers

Personal clouds and “fogging”◦ Cloudfogger.com (local encryption prior to uploading)◦ “MyCloud” products by Western Digital◦ Personal servers


E-therapy and assessment How do you (or will you) provide assessment and treatment services using remote transmission or taking advantage of remote storage?

Ethical issues (4 C’s):◦ Competence (and treatment efficacy)◦ Confidentiality (security of communications and consent)◦ Crises (availability for effective intervention)◦ Cross-jurisdictional challenges

Novel hazards:◦ Are you ready to see edited clips of yourself on YouTube?


When the licensing board (or ethics complaint) comes calling

142

“Some guys from the state licensing board are here to see you.”

To err is humanDiploma

Mill University

Mistakes Happen

My mother loves me


Dealing with Licensing Board and Ethics Inquiries

Know who you’re dealing with and understand the complaint process◦ Statutory board or voluntary professional association◦ Psychologist or lay investigator◦ Informal inquiry or formal charge (Don’t treat any communication as “informal” even if that language is used.)

Understand the precise complaint, rules, and procedures◦ You are entitled to information on the charges or complaint ◦ You should be given or referred to a copy of the procedures to be followed or rules that apply, and a release

of your duty of confidentiality to a complaining client.◦ Do not contact the person who complained.◦ Do consult with professional colleague (on an official basis, not “as a friend”) or attorney before responding.◦ If asked to provide materials in response to an authorized release, send copies and preserve the originals.◦ Do not agree to a preliminary settlement or consent order without sound legal advice


Dealing with Licensing Board and Ethics Inquiries

Organize your defense and response carefully◦ Compile documents and event sequences that address the credibility of the complaint.◦ Limit the scope of your responses to the scope of the inquiry.◦ Even though you may have an attorney, you will be expected to respond personally, so do not defer all

communication to counsel.◦ If you need more time to compile materials an respond, ask for it.◦ Even if you feel wrong charged or offended, do not respond with a thundering offense against the

complainant. State your own case clearly and document your supporting points.◦ If you have committed the offense charged, document the events and begin remedial steps (e.g.,

seeking supervision, entering therapy, etc.) even while the case is pending to demonstrate good faith and rehabilitative intent.

◦ Do not accept formal disciplinary findings without a hearing, unless following the advice of counsel.◦ Know your rights of appeal.


Documents

Preventing & Managing Common Ethical Predicaments GERALD P. KOOCHER, PH.D., ABPP DEPAUL UNIVERSITY