Ethical Dilemmas and Overlooked Issues in Private Practice

NASW Conference 04.02.15

Kate McNulty LCSW

CreateYourPrivatePractice.com

Social Work Core Values

• service• social justice• dignity and worth of the person• importance of human relationships• integrity• competence

Ethical DILEMMA Defined

• SW must make a decision about best course of action

• A choice is involved • Arriving at a decision will involve some

compromise of one or more ethical principles

See socialworker.com, What is an Ethical Dilemma

Ethics

Professional standards based on logic and reason, rationality

Cognitive tools used to arrive at a best solution

Root of rational is ratio, reckoning

ValuesConcepts that are honored

Aspirational ideas with a component of emotion: root of the word aspiration in Latin is related to longing for, seeking after

Morals

Code of conduct for one’s own behavior

Provides guidance for our relationship life

Laws and policiesPrescribed conduct for one’s professional role

Mandated or prohibited behaviors for all members of a society

SW ethics include obligation to challenge unfair laws and policies

When Bad Things Happen to Good Social WorkersGreat article for those interested in more detail on SW ethics: Frederick Reamer, socialworktoday.com

E-T-H-I-C

• Examine relevant personal, societal, agency, client and professional values

• Think about what ethical standard of the Code applies + laws and case decisions

• Hypothesize about possible consequences of different decisions

• Identify who will benefit and who will be harmed• Consult with supervisor and colleagues about most ethical

choice• Elaine P. Congress, What SWs Should Know about Ethics

Qualities needed to make thoughtful ethical decisions

• Cultivate reflective time and attitude• Receptive to and valuing of feedback• Humility• Lifelong learner• Discernment about associates you choose• Cultural competence• Technological competence

Colleagues should let you know if you’re off trackDevelop candid relationships with people you trust so you get regular feedback on your clinical judgment and decision-making.

Support structures for arriving at reasonable ethical outcomes

• Paid consult in 1:1 or group format

• Plentiful and frequent continuing education events

• Risk management consults through malpractice insurer

• Peer consult in 1:1 format or as needed

• Participate in NASW Board or other organization

Role of Licensing Board

If you are the subject of a Board inquiry, consult an attorney before responding to any letters or phone calls.

The Board is not your advocate.

The Board acts to protect the concerns of clients and members of the public.

They pursue inquiries and investigate complaints about possible wrongdoing by licensees.

It is your responsibility to protect your livelihood and license by seeking advice from a malpractice attorney.

Promoting your practice ethically and effectively

Free first sessions?This is often used as a marketing technique but introduces some possible confusion at the start of the relationship:

Are they your client in a free first visit?

Does this serve as a screening process for you?

Do they complete introductory paperwork?

What liability do you carry if they choose not to return?

Are you causing harm, if after an initial visit you decide to refer the client elsewhere?

Is this the most effective use of your marketing time and energy?

TestimonialsWhile clients may offer favorable comments, all codes of ethics prohibit soliciting or employing client testimonials.

You may use testimonials from non-therapy relationships like classes and workshops.

Claims about resultsWe cannot imply or make promises about outcomes of our work

That might mis-lead prospective clients or suggest that they can expect the same results other clients have experienced

Wait listsBusy therapists sometimes create waiting lists. Is this in the best interests of the client?How can you know the client is appropriate for a wait list if you haven’t met them?

What about the concept of client readiness or urgency?

How do we set priorities?

What about considering the client’s need for treatment versus our business and monetary concerns?

Thanking referral sources

It is good business to thank referral sources for the clients they send. They also appreciate notification of the results of their referrals.

Our obligation is to protect client privacy, so even simple notes of appreciation should only be sent after we have obtained a release of information, so we have permission to communicate.

Media inquiriesAt times you may receive calls from media personnel looking for comments on news stories. They are often urgent in their manner.

You should not offer diagnostic opinions about people you have not met, even if you are asked about well-known celebrities.

Complex situations involving confidentialityMaintaining confidentiality with children, teens and families can be especially complicated. Using plain language, carefully explain informed consent and limits of confidentiality in advance.

Cases involving divorce and step-parenting are also difficult; obtain written consent of both parents unless one has sole custody and there is a good clinical reason to exclude the other parent from therapy.

Group work with teens is another place to exercise special care with boundaries and information-sharing.

Explaining limits of confidentialityEnsure clients understand what information you will and will not disclose, before the question is raised. Take all the time you need to review this in detail, so you use these concerns to build on rapport.

Inquiries to be aware of

• You should refer out cases like this unless you are qualified to treat them as a specialist:

• Forensic cases• Disability evaluation• Fitness for duty (police, transport

professionals)• Court mandated evaluations• Child custody evaluations

Many problems can be prevented through proper screening at the time of the initial inquiry

Be prepared to turn away these cases and have referrals at the ready if you often receive inquiries about problems like this

Child custody & Divorce cases• Don’t bite off more than you can

chew- nor take on a professional role if you are not trained for it.

• Leave comments and legal opinions on parenting arrangements to qualified child custody evaluators.

• Divorcing clients may seek your advocacy; provide them with professional referrals and continue offering therapeutic support to them. Do not cross professional lines. Seek consultation from a colleague or advisor if you are not sure how to proceed.

Dual relationshipsDual relationships: are they necessary, or avoidable? Can you see the forest for the trees?

May be impossible to avoid in rural setting or in sub-communities in urban areas

May see current or former clients in community contexts

Can still maintain professionalism and limit the types of conversations and interactions that occur outside the therapy space

Other potential compromises in confidentiality

• Shared office spaces• Shared waiting rooms• Shared file cabinets and storage• Advice and referrals on listservs• Curbside consultations

Boundary crossings and violations

“Out of office experiences” may be unavoidable; not necessarily harmful

Responding to emergencies may include phone contact outside office hours

Assess effectiveness of soundproofing in your office

Artwork and furnishings in your space: are they comfortable and welcoming for all? Do your furnishings include religious or spiritual imagery that could alienate some people?

Scope of practice and limitations

• Stay within realm of your training and expertise

• Demonstrate that you are truly specialized in certain topics

• Refrain from claiming mastery of too many subjects

• Maintain ongoing training, reading and research

• SW Code states you must be culturally competent and equipped to treat diverse populations

Details of informed consent Allow time for thoughtful and thorough conversations about consent

A signature on a form is only the beginning

Obtaining consent involves ongoing discussions and evaluation of your technique and the results you’re achieving

Make sure fee and terms of treatment are agreeable

Obtain signature if you are on panel and client elects not to use insurance

Secure written permission to work with collaterals as needed

Provisions for reasonable care

• If you end therapy with someone due to a poor fit or your lack of expertise, you must find them some alternate sources of treatment

• For this reason and many others, your practice should include a multitude of connections with other clinicians and professionals

• Most states oblige you to have a peer who agrees to act as conservator of your practice in case of disability or death

Moving, closing or retiring from a practice

• Review contracts with insurers and provide adequate notice in the event of closing your practice

• Take clients’ ongoing care needs into account and prepare to make appropriate referrals

• Allow enough advance notice to ensure clients are connected with new providers

• Review state requirements for storage of records• If leaving records stored, assign a qualified person to retrieve

in the event of a subpoena or other necessary circumstance

Keep good records and maintain good clinical habits. You will end your career on a high note, ready for the next chapter of your

life.