I hope you have found the report of the Division of Psychotherapy’s Task Force on Psychologist-Psychotherapists and its accompanying review of the relevant psychotherapy research literature to be of interest and value.

Please share your thoughts, comments, and recommendations below. If you know of other research relevant to this project that you would like to share with us please let us know here.

While the work of the Task Force has been completed, the Division 29 Science and Scholarship Domain, chaired by Norman Abeles, Ph.D., and its Psychotherapy Research Committee, chaired by Susan Woodhouse, Ph.D., will contine this important project. They will be reviewing and responding to all comments provided here and considering for inclusion in our literature review all additional relevant studies you share with them here.

Thank you in advance for your input and support. On behalf of the members of TOPPS – Jeff Barnett

I am curious about ethical considerations when treating individuals who are HIV positive. What are my responsibilities as a clinician if I know that my client (HIV positive) is engaging in risky/unsafe sexual practices with someone? In this case, the other person’s life is endangered.

This issue always stumps me, thank you for your thoughts!

Jeff Barnett Responds:

Hi Stephanie. Great question. This is one that often is very confusing and challenging for psychotherapists. One of the major concerns involves the different but related roles of ethics, law, and clinical practice. I believe some of what is behind your question concerns the issue of “duty to warn and protect” that comes from the landmark Tarasoff decisions in 1974 and 1976 (Tarasoff v. Regents of the University of California.

In 1974 in the initial ruling the court opined that “where a psychotherapist had reason, arising out of a professional relationship with a patient, to believe, or reasonably should have believed, that the patient was intending to harm a specific victim, that a duty existed to warn that victim” (Mills, 1984).

In 1976 the court revised and updated its opinion, adding to the obligation to warn the intended victim with the need to take actions to protect the intended victim such as by contacting the police, and possibly by even using treatment to prevent the harm from occurring.

The Tarasoff rulings set legal precedent. But, over the years as states have passed laws to address these issues, the precedent has been codified into law. Yet, various states’ laws are different in their requirements. Some states have duty to warn statutes, some have duty to protect statutes, some have duty to warn and protect statutes, and some include treatment in their statutes. For example, in Maryland , the law is the duty to warn, protect, or treat. That is, if treatment can prevent harm to another person from occurring , it should be used first. Confidentiality should only be breached in these situations when treatment is ineffective or is not possible.

But, it is important to note that the Tarasoff rulings and these various state laws are speaking of a specific threat made in treatment to do harm (typically interpreted as lethal harm) to an identifiable victim or group of victims. This brings up several important points. First, it must be a threat to do harm. This implies that the harm did not already occur. The goal of these laws is to prevent future harm. Second, it must be an identified victim, otherwise who would we warn and who would the police potentially take action against? Third, the harm that is threatened should be lethal. If a client said in session that later that day they are going to punch their spouse, this would not meet the standards needed for breaching confidentiality.

But, if one’s state law allows for this the psychotherapist should always consider treatment as the first option. These laws do not require that the psychotherapist make a call to the intended victim and to the police the moment a client discloses such a threat. We are to conduct a thorough risk assessment, address these issues in the treatment plan, and work to address underlying issues, in an effort to prevent the harm from occurring, and thus, to prevent the need to breech confidentiality.

With regard to the issue of a client with HIV or AIDS disclosing engaging in unprotected sex with other individuals this is of course a very serious concern that will hopefully be addressed in treatment. With regard to breaching confidentiality there are several issues of relevance and great importance. First, it is essential that we always include potential limits to confidentiality in our informed consent agreements with our clients.  Then, the following factors are relevant: intent to do harm, likelihood of actual harm occurring, the inability to know the identity of future sexual partners, and the likely presence of consent to engage in these behaviors (Chenneville, 2000). When it comes to unprotected sexual behavior one might reasonably argue that your client’s partners are engaging in this behavior consensually. To date there has been so much education about sexually transmitted diseases, practicing safe sex, and the like, that this situation can be seen as substantively different than the typical Tarasoff-like situation. Of course, if your client stated in session that he was going to rape a specific individual in the future and to do so without a condom, that might more closely approximate the need for the Tarasoff-like actions described above. But, when considering lethal actions, unprotected sex by an HIV-Positive or AIDS-infected individual is does not possess the lethality of shooting, stabbing, etc. another person. The rate of transmission of HIV from unprotected sex is not even close to 100% and for those who are infected there now exist effective treatments.

Thus, it is important to keep in mind the requirements of your state’s laws. This includes duty to warn, protect, and treat laws as well as those relevant to reporting HIV. Some states do not all the reporting of HIV or AIDS status by licensed psychotherapists (e.g. Wisconsin) while other states require the reporting of it (e.g. Washington). So, knowledge of the relevant laws in one’s jurisdiction is essential. It is also important to keep in mind that breaching confidentiality due to harm to others has strict limitations. The harm must be threats of harm in the future, not in the past or ongoing. Additionally, the harm typically must have potentially imminent lethality (again, check your state laws for their specific wording). Finally, if these issues can effectively be addressed in treatment, that is preventing the risk of future harm through treatment, that should carefully be considered unless your state’s law contraindicates this. When addressing these issues are addressed in treatment it is important to thoroughly document all discussions, recommendations, interventions and actions taken, your client’s responses, and all consultations. Further, it’s not just important to document what you did, but also all that you considered and the rationale behind your decisions.

I hope this is helpful to you. I do not represent myself as an attorney or an expert on every jurisdiction’s laws, and I do not know all the details of your case. But, I do hope this provides some issues for consideration and discussion. Please feel free to share your comments and any additional thoughts. I also welcome other members sharing their thoughts and perspectives on this important and challenging issue.

References

Chenneville, T. (2000). HIV, confidentiality, and duty to protect: A decision-making model. Professional Psychology: Research and Practice, 31(6), 661-670.

Mills, M. (1984). The so-called duty to warn: The psychotherapeutic duty to protect third parties from patients’ violent acts. Behavioral Sciences & The Law, 2(3), 237-257.

As graduate students we receive training not only in academia but in a myriad of different clinical settings, which often lead to a wide range of experiences in terms of supervision. Because of the emphasis that is placed on clinical/practical training for clinical psychology programs in particular a graduate student’s competencies are strongly related to the quality and type of supervision that he or she receives during practica experiences.  Given this, how important do you think it is for supervisors of graduate students to receive training in the area of supervision?  Should there be specific competency requirements for psychologists or other mental health clinicians who plan to train graduate students?

Jeff Barnett Responds:

This is a really important question. Clinical supervision is an essential aspect of every psychologist’s professional training. We each participate in supervision during different stages or phases of our professional growth and development. Without it, we couldn’t develop the competence needed as professionals. Yet, the quality of the supervision we receive is of great importance. Inadequate, unethical, or insufficient supervision has serious ramifications for our developing competence as well as for the clients to whom we provide professional services.

Competence is generally thought of as being comprised of knowledge, skills, attitudes and values, and the ability to implement them effectively. In general, we obtain much of the knowledge we need from academic course work, reading, attending seminars, and the like. We also should be able to obtain additional knowledge from our clinical supervisors. Our skills are developed primarily in clinical supervision. Our supervisors also serve as professional role models; we learn and develop many of our professional attitudes and values from the examples set by our supervisors.

It is essential that supervisors possess two major types of competence; competence in the clinical areas they are supervising and competence in being a supervisor. It is definitely important that supervisors have training in being a supervisor. Like any other clinical role, it has it’s own literature, research, and requisite skills. Merely having been supervised in the past is not a sufficient credential for being a supervisor. Also, just because a job may require a psychologist to supervise a certain number of trainees, that doesn’t mean one is competent to provide the supervision. One must first obtain the necessary training to develop needed competence so that one may provide supervision skillfully and ethically. There are different models of supervision, various methods of supervision, and a number of clinical and ethical issues supervisors should be aware of.

Some jurisdictions require clinical supervisors to have  a certain number of hours of continuing education in clinical supervision for their license to be renewed every two years if they are to provide clinical supervision. That’s a good start, but a minimal requirement. Training programs should require that potential supervisors submit documentation of their training, experience, and competence in providing supervision before being allowed to supervise students. This may involve submitting continuing education certificates, transcripts, a statement of professional experience, and/or letters of recommendation. But, often training programs have a difficult time getting supervisors for their students since the supervisors are often volunteers. As a result, programs may just be glad to get supervisors for students and may not be as careful or thorough in screening potential supervisors. Just as supervisees receive written and verbal feedback throughout the course of supervision, perhaps supervisors should receive written feedback and evaluations from supervisees that are shared with training programs.

There are also many ethics issues that supervisors and supervisees should be aware of. Additionally, there’s a body of research that highlights the qualities of effective and ineffective supervisors (and supervisees!) that both supervisors and supervisees should be aware of. I also believe that there should be an informed consent agreement or supervision contract completed at the outset of the supervision relationship that clarifies all roles, responsibilities, obligations, and the like. These issues and other relevant ones are addressed in the PowerPoint slides below that are from a presentation on the topic I gave recently.

I hope this is helpful. If you have any comments in response to what I have written here or if you have other questions please don’t hesitate to ask. I also welcome others’ comments and questions as well. I wish you much success in your training. A final thought is to keep in mind that as a supervisee, you are an active consumer of a service. You must be provided with the needed oversight, training, supervision, mentoring, and role modeling that are needed for you to flourish and develop as a professional psychologist.

Best wishes – Jeff

Ethical and Legal Issues in Supervision

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I have a client (18yr female) who I have seen twice a week for 8 months who is currently in a relationship plagued with intimate partner violence. This has been dubbed “mutual combat” by several of my co-workers, but in exploration with her, it appears as though the severity of his violence, his physical strength, and his emotional control create a dynamic where she sometimes reacts with violence (i.e., pushing him so she can escape, scratching his arms when they are around her neck). She has asked to begin couples therapy with her partner, and he has agreed. I am familiar with some of the literature on couples therapy and intimate partner violence and have had some training in this area, but no one else at my location (a community mental health center) is trained in couples therapy and/or intimate partner violence. My agency is now discussing the possibility of me seeing them as a couple while continuing to see her. Are there guidelines or best practice recommendations about
whether it would be appropriate for me to see them as a couple?

Response by Jeffrey Barnett

Thanks for this great question. I’m really glad you are asking it. Clearly you are sensitive to the issue of competence with regard to the knowledge and skills needed to provide couples therapy. As your question implies, being competent in individual psychotherapy doesn’t necessarily translate over to clinical work with couples. Once must have the necessary education and training from course work, readings, CE activities, and supervised clinical experience before expanding our practice into a new area. I agree with you that you need to be aware of relevant practice standards and guidelines as well.

The situation you describe is also challenging because of the highly volatile nature of the relationship and the risks present for all involved (including yourself!). It will be important to be sure you have in place safeguards to protect yourself should anyone become aggressive or violent during a session. Having a colleague present or nearby during sessions, having a ‘panic button’ at your desk to quickly summon security if needed, positioning yourself near the door and not having clients seated between you and the door each may be important. Additionally, having a treatment contract/informed consent agreement that clearly specifies rules of conduct for the psychotherapy relationship is important as well. It should specify acceptable and unacceptable behaviors, appropriate alternatives to use if one is angry, and responses or consequences that will occur should certain specified behaviors happen.
With regard to the competence issue and relevant standards I suggest you consult with colleagues who are experts in couples therapy and in clinical work with intimate/partner violence. APA’s Division of Family Psychology and the Family Psychology section of the American Board of Professional Psychology may be good resources. While you may not have a competent supervisor on site, consultation and supervision may be done across distances by use of televideo communications such as Skype or by telephone and by sending the supervisor tapes of sessions with appropriate consent of the clients.

You are wise to be concerned about practicing in a new area without first knowing relevant practice standards, obtaining needed education and training, and receiving ongoing consultation or supervision. Then, should you proceed with this case, be sure your expert colleagues provide suggestions on how to structure the treatment sessions and relationships to ensure the safety of all involved. I hope this is of help. Should you have additional questions or comments please let me know. I also hope others will share their thoughts on this important area of practice as well. Perhaps some colleagues who work with these types of couples can share their perspectives.

Thanks and best wishes – Jeff

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Currently, there is a push for people to be on medication, and clients often come in stating that they want medication. This is especially true in multidisciplinary environments where psychiatrists and APRNs work alongside psychotherapists. However, some people do not have this mindset. For therapists who believe that medication only needs to be used as a last resort or in obvious serious situations, is it ethical to not refer everyone to a med provider, and instead of offering medication right off the bat, to wait and try and achieve success in therapy first, in the hopes that medication will not be needed?

Response By Jeffrey Barnett

This is a great question and one that all psychologists and psychotherapists should carefully consider.  It is true that some mental health patients must have medication included as a part of their treatment. These may include those suffering from Bipolar Disorder, Schizophrenia, and other serious mental illnesses. But, even for these patients, we know that medication alone does not provide the best treatment outcomes. Even for these patients, psychotherapy and psychoeducation are important components of their treatment. Many of these patients struggle with medication compliance for a variety of reasons to include side effects of their medication. We also know that for many mental health patients, even those for whom medication may be of help, that many of them will also benefit from psychotherapy alone or a combination of psychotherapy and medication. Fairly recent data demonstrate that psychotherapy can result in many of the same changes in the brain that medication causes, and without the significant side effect potential or the potential for drug-drug interactions.

It is unfortunate that we live in a time where pharmaceutical companies directly market their products directly to consumers and the health insurance and managed care industries often take a myopic view due to fiscally motivated treatment decisions. Some patients may not be allowed to see a psychotherapist under their insurance plan until they have tried and failed with two or three medications. That’s really tragic, especially with all we know about the effectiveness of psychotherapy.

I believe your question brings up several important ethics issues. The first is informed consent. It is important to share all reasonably available information with your clients to assist them in their decision making. While we shouldn’t overwhelm them with information, it is important to ensure that they understand the reasonably available options and alternatives for their treatment along with their relative risks and benefits. This will then assist them to make more thoughtful and informed treatment decisions. The second important issue is that of competence. If we aren’t sufficiently knowledgeable about psychopharmacology and psychotherapy we can’t provide the relevant information and can’t effectively assist patients to make the most informed decisions possible.  We should also explore with patients their motivations for wanting medication. They may be seeking a quick and easy ‘fix’ for their difficulties. Again, providing them with relevant information will assist them to have realistic expectations of treatment whether psychotherapy alone, medication alone, or a combination of the two. Finally, when our psychotherapy patients are being treated with medication it is important that we address confidentiality and consultation issues with regard to coordinating treatment with their prescribing physician (or other professional). We should ensure that we have appropriate consent from our patients before sharing information with others, but should stress the importance of coordinating care with our patients. We can monitor for side effects, positive effects, and the like. The prescribing professional may only meet with the patient for 15 minutes every 6 months whereas we may meet with the patient for 50 to 60 minutes each week.  For those patients taking medication in addition to our psychotherapy we can play a valuable role in monitoring their functioning and progress.

We can also work to educate prescribing professionals about the short and long term benefits of psychotherapy for a wide range of presenting problems. In the multidisciplinary environment it can be very important to provide inservice training on psychotherapy. You could also provide consultations on patients at intake and explain treatment options then.

There is not obligation to refer all patients to a prescribing professional right away, but this goes back to the points raised about informed consent. One thing you can do is in your practice literature (as well as on your website if you have one) you can describe the services you offer along with your treatment approach and practice philosophy. That may be a good way to let patients and potential patients know how you approach treatment for a range of presenting problems. Then, if they still want to meet with you could go through the informed process as described earlier. But, you should endeavor to provide patients with accurate information, not just personal opinion. Also, it is important to ensure that all patients are medically cleared for treatment and if medical conditions exist that may impact their treatment referral for appropriate medical care is essential (e.g., diabetes, hypertension, etc.).

What you ask about is a true ethics dilemma; that is, there is no clearly correct or incorrect course of action. The best course of action depends on a number of issues and factors as described above. What makes your practices ethical or unethical is the actions you take, the actions you choose not to take, and the rationale for doing so (along with following the dictates of the ethics code and relevant state laws).

I hope this is of help. If you have additional questions or comments please post them here. Thanks for seeking this consultation. I hope others can benefit from reading it and will respond as well.

Best wishes – Jeff

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I have a female client I have seen for several years (abusive marriage then divorce and a very recent re-marriage). She has moved with her new husband about two hours away and does all her work by computer, so she doesn’t come to Atlanta anymore. She asked if I could do “phone therapy” with her. I am guessing probably every other week (at the most) and once a month (at the least). She doesn’t use insurance. I would prefer that she just come down to Atlanta once a month, but she has two kids and a full time job, so it’s not so easy to do. I am guessing this “phone therapy” wouldn’t be for much longer, maybe just two to three times, but I’m not sure. Thanks for your input on this matter.

Response by Dr. Barnett.

Hi Betty. Good questions. There are a few relevant issues. If this is just for a few sessions to tide her over until she can find a new psychologist in her local area or to help her with the transition to her new situation, and thus is time limited, it is much more appropriate. If this is to be the primary form of treatment over an extended period of time it raises several concerns. Can telephone contacts replace in-person
psychotherapy? A lot of that depends on the client’s treatment issues and needs. For some clients this may actually appropriately meet their clinical needs. For others it may prove insufficient. Doing a careful assessment is important and documenting all options considered and relevant factors, pros and cons, the rationale of your decision, and the actual decision. Then, you will want to be sure to fully address these issues in the informed consent process (an ongoing process where you address any significant changes to the treatment contract). It is also important to familiarize yourself with resources in the clients local area so you can access them or
refer her to them should she experience an emergency. Since she’s two hours away and not 12 hours away for example, this may be less pressing an issue, but still important to address proactively. Also, since the client is still in the same state you don’t need to consider licensure issues; you’re not providing services across state lines. That could be problematic. But, even with that, two phone calls when a client is on vacation or on a business trip is very different than providing ongoing treatment via telephone (telehealth/e-therapy) across state lines.

I suggest discussing with the client her needs and her reasons for wanting this type of continued contact with you. If a call once or twice per month for a couple of months is all that is needed it should be less an issue than if this is ongoing treatment. But, any agreement struck with your client should also include what will happen if her treatment needs change. Initial agreements that sound reasonable at times need to change due to changing circumstances for the client. If she needs more intensive treatment will you provide her weekly telephone sessions for an extended period of time or will the agreement stipulate that she will then accept one of the referrals for in-person treatment in her local area that you provide to her?

These are some issues to consider. As always with ethical dilemmas there is no one right answer, but rather, several issues, factors, and options to consider. Also, closely monitoring the situation and having needed agreements in place are all important. I hope this is of help. If you have additional questions or reactions to this response please let me know.

Thanks and best wishes – Jeff

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Jeffrey Barnett

Jeffrey Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola Univeristy Maryland and a licensed psychologist in practice in Arnold, Maryland. He is a Diplomate in Clinical Psychology and in Clinical Child and Adolescent Psychology of the American Board of Professional Psychology and a Distinguished Practitioner of Psychology in the National Academies of Practice. He is a recent past chair of the Ethics Committee of the American Psychological Association and has previously been chair of the Maryland Psychological Association Ethics Committee. Dr. Barnett has published numerous articles, chapters, and books on ethics and professional issues in Psychology and has given numerous presentations and continuing education ethics workshops for psychologists and other mental health professionals. His most recently published books include Ethics Desk Reference for Psychologists (APA Books, 2008, with Brad Johnson), Ethics Desk Reference for Counselors ( ACA Books, 2009, with Brad Johnson), and Financial Success in Mental Health Practice (APA Books, 2008 with Steve Walfish).

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Linda asks a number of very important questions about the role the use of technology in research and practice, to include the recording (audio and/or visual) psychotherapy sessions, supervision, peer consultation, research, and presentations.  Additional questions concern the role of informed consent when making such recordings, the role of HIPAA and other confidentiality and privacy issues, and ethical practices concerning the solicitation of research participants, the use of inducements or incentives to participate in research, and related issues.  There is perhaps a book or two in the responses to all these questions and I do hope that my responses will stimulate further discussion by Linda and the readers of this blog.  I will not try to respond to every aspect of this question all at once, but will respond in several pieces.  This will hopefully enable closer examination and exploration of each issue and the greater opportunity for discussion.

Once component of the questions raised involves the role of the use of various technologies in practice and research. As Linda highlights there presently is a dearth of guidance for ethical practice when integrating various technologies into our practices.  In the Introduction and Applicability section of the APA Ethics Code it mentions that the Ethics Code applies to all the roles and functions of psychologists “across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions” (p. 1061).  Thus, it is reasonable to assume that the APA Ethics Code must be considered, and its standards followed, when utilizing various technologies in our professional activities.

Some specific standards to consider include:

• 2.01 Competence: We should ensure that we are competent in the use of the specific technologies involved and obtain the education, training, and experience needed to maintain this competence. Further, in areas where standards do not exist psychologists “take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participant, organizational clients, and others from harm” (p. 1064).

• 3.04 Avoiding Harm: We should take all reasonable steps to anticipate harm that may occur from our actions or lack of action, and work to prevent or minimize harm to the best of our abilities.

• 3.10 Informed Consent: This may be one of the most significant standards and one that may stimulate the most discussion.  We must ensure that those we treat, assess, study, supervise, etc. are informed of all significant information that might impact their decision to participate, prior to the professional activity is provided.  This consent should be given voluntarily and not be given under duress or in response to coercion, the individual should be competent (legally and cognitively/emotionally) to give their consent, we need to actively ensure their understanding of what they are agreeing to, and the consent should be documented.  Further, important issues such as limits to confidentiality, reasonably available options and alternatives and the risks and benefits of each, the right to refuse participation and the right to withdraw from participation without penalty, each should be addressed.  Additional specifics of informed consent are provided in the APA Ethics Code as well as in one’s relevant state laws.

• 4.01 Maintaining Confidentiality: The use of various technologies can greatly impact confidentiality and reasonable steps to protect each participant’s confidentiality is essential.

• 4.02 Discussing Limits of Confidentiality: This is one of the essential aspects of the informed consent agreement and process that is discussed above.  This standard includes: “Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality” (p. 1066).

• 4.03 Recording: This standard states specifically that “Before recording the voices or images of individuals to whom they provide services, psychologists obtain permission from all persons or their legal representatives (See also Standards 8.03, Informed Consent for Recording Voices and Images in Research; 8.05, Dispensing With Informed Consent for Research; and 8.07, Deception in Research.)” (p. 1066).

• 4.07 Use of Confidential Information for Didactic or Other Purposes: This standard is of great relevance to the aspect of Linda’s question that concerns the use of information from clients, supervisees, research participants, etc. in our writings, presentations, and the like.  This standard and its implications will be discussed in much greater detail when addressing these issues.

• 5.01 Avoidance of False or Deceptive Statements: This standard is relevant to all public statements made such as in writing, presentations, or through various technologies.  We must ensure accuracy of the content of these statements as well as in our basis for sharing the information (e.g., fully informed consent).

• 6. Record Keeping and Fees: This section of the Ethics Code contains several sections relevant to record keeping.  They emphasize the need to protect and maintain the confidentiality or records and “data relating to their professional and scientific work” (p. 1067), which should be seen as including all recordings of professional interactions.  Records are not limited to session notes, assessment reports, and other written materials. All recordings, tapes, or any other media that record information about or of those we provide professional services to should be considered as falling under these standards.

• 9.02 Informed Consent in Assessments: Any use of recordings when conducting assessments must be carried out with all the other applicable standards of the Ethics Code that have been addressed above.

• 9.11 Maintaining Test Security: Should recording of assessment be done, the issue of test security must be considered.  Those tests and assessment tools with a limited domain of stimuli must have their security protected to help ensure their ongoing validity and usefulness. Additionally, there may be copyright and other legal issues to consider as well.

• 10.01 Informed Consent to Therapy: This standard provides additional detail to the discussion of informed consent above, and applies it specifically to psychotherapy.

With regard to the issues raised regarding research, Section 8: Research and Publication, contains several standards relevant to the questions raised.  These will be addressed in detail in a later blog posting, but include:

• 8.01 Institutional Approval

• 8.02 Informed Consent to Research

• 8.03 Informed Consent to Recording Voices and Images in Research

• 8.05 Dispensing With Informed Consent for Research

• 8.06 Offering Inducements for Research Participation

• 8.07 Deception in Research

What Linda did not ask about and what will not specifically be addressed unless raised by others for discussion is the role of using various technologies for the provision of psychological services, such as telehealth, E-health, E-therapy, and the like.  These can include telephone and E-mail communications with clients in between in-person sessions as well as providing supervision or treatment across state or national borders via the Internet to include by E-mail, social networking sites, or Interactive Tele-Video Communications (IATV) such as Skype or other similar audio-visual communication via the Internet.  These bring with them great opportunities and potential benefit as well as a number of clinical, ethical, and legal challenges and dilemmas.

In my next posting I will begin specifically addressing:

• The role the use of technology in research and practice, to include the recording (audio and/or visual) psychotherapy sessions, supervision, peer consultation, research, and presentations

• The role of informed consent when making such recordings, the role of HIPAA and other confidentiality and privacy issues, and ethical practices concerning the solicitation of research participants

• And then the use of inducements or incentives to participate in research, and related issues.

Again, all readers’ comments, thoughts, and questions are most welcome.  Best wishes – Jeff

Here is Part II of my response:

Before getting into the specifics of how to appropriately record a client, supervisee, peer, or research participant, I think it is important to ask why you are wanting to do this.  In psychotherapy we all must appropriately document the services we provide.  Are you thinking that recording the sessions is how you will document them?  If so, will you archive and maintain each recording in compliance with the requirements of relevant state and federal (e.g., HIPAA) laws?  Or, is there some other reason for making these recordings?  Whatever your objectives, it is important to ensure that making these recordings is the best (and most appropriate) way of achieving these goals.  If there are other options available to achieve your goals and objectives, they should be considered as well.

Should making these recordings be clinically relevant and important to do, then as you mention, it is vital that this is fully discussed in the informed consent process prior to making any recordings.  The other individual(s) should fully understand the reasons for making the recordings, how they may be used, how this potential use is relevant to the reasons you are meeting with them (e.g., how is making these recordings going to contribute to or enhance their treatment, supervision, etc.?), will they have access to these recordings and if so, how, how long will the recordings be maintained and where, and when destroyed, how will this be done?

As with all informed consent agreements it is important that the other individual’s consent be given voluntarily, that she or he is competent to give this consent (cognitively/emotionally as well as legally), that you actively ensure her or his understanding of what is being agreed to, and that the informed consent agreements are documented.  Further, consistent with the APA Ethics Code reasonably available options and alternatives should be discussed along with the relative potential risks and benefits of each along with the relative potential risks and benefits of refusal.  Finally, they should understand that they may rescind their authorization or consent at any time without penalty or adverse consequences.

The use of recordings in supervision is widely known.  Trainees regularly audio or videotape sessions with clients for their clinical supervisors to review, both prior to meeting for supervision and jointly in supervision sessions.  It can easily be seen how this use of recordings of sessions with clients  can be of benefit to the clients (as well as to the trainees).  But, due to the high likelihood of benefit to the clients an argument can be made that the use of recordings in this way is ethically and clinically appropriate, and consistent with the APA Ethics Code (as long as informed consent requirements are followed as discussed above).

But, the practice of recording treatment sessions by practicing psychotherapists, the practice of recording supervision sessions by supervisees, and the practice of recording peer supervision/consultation sessions by a member of that group are each less clear.  How will these recordings be used to benefit the members involved.  In peer supervision/consultation having recordings could be of value to group members.  Additional review of group discussions and feedback provided could be quite beneficial to participants.  How the recordings would be used and what benefit or value would result from having the recordings is less clear.  This would have to be clarified before making a decision about engaging in this practice.

In research, the use of recordings is a widely accepted practice.  Often, this is an integral component of the research.  For example, in studies of mother-infant interaction, the recordings are analyzed to discern significant patterns and dynamics.  The use of recordings is integral to the ability to conduct the research.  So, again, one must determine the relevance of the use of recordings, fully address it in the informed consent process, and ensure appropriate safeguards and security protections to minimize the risk of unauthorized access to these recordings.  Participant access to their records and any recordings made should be addressed in the informed consent process as well and compliance with institutional policies and federal and state laws are important as well.

In my next posting I will address the solicitation of research participants and the use of incentives to encourage participation in research.  As always, I welcome all comments, reactions, and questions in response to what I have posted.  Best wishes – Jeff

Here is final portion of my response:

The issue of offering incentives or inducements to potential research participants is addressed specifically in Standard 8.06 of the APA Ethics Code.  This standard states:

(a) Psychologists make reasonable efforts to avoid offering excessive or inappropriate financial or other inducements for research participation when such inducements are likely to coerce participation.

(b) When offering professional services as an inducement for research participation, psychologists clarify the nature of the services, as well as the risks, obligations, and limitations. (See also Standard 6.05 Barter With Clients/Patients). (p. 1070)

Thus, this practice may be engaged in, but it must be done so with appropriate forethought and caution.  The first part of this standard is consistent with the previous discussion of informed consent, which we must ensure is given voluntarily.  If the inducements are such that there is a coercive effect, then this is inappropriate and violates the APA Ethics Code.  For example, let’s say I am doing a study with human participants that holds many risks, requires a significant time commitment, and may be of little value to the participants.  To solicit participants I stand outside of a Methadone Clinic in an inner-city setting and offer patients there $500 for their participation in the study. This could be seen as preying on their vulnerabilities and taking advantage of their circumstances.  All use of inducements must occur without coercion.  Further, all research protocols to include the recruitment of participants should be reviewed and approved by an Institutional Review Board (IRB) prior to initiating any of these activities.

As you mention, some researchers offer participants various services in return for their participation in the research study.  Examples may include a physical exam, nutritional counseling, psychotherapy, and the like.  Consistent with the part (b) of Standard 8.06 all this must be addressed fully in the informed consent.  Further, the offer of such services as an inducement for participation in the study must be consistent with part (a) of this standard as discussed above.  If psychotherapy or other treatment services are being offered in return for participation in the study it is important that all other relevant standards of the APA Ethics Code be followed to include informed consent, competence, avoiding harm, and multiple relationships. Each must be carefully considered prior to engaging in these practices.  The use of colleagues for consultation and the use of an IRB in all research planning are extremely helpful and important as well.

Best wishes – Jeff

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I have a client referral who is requesting, via an anonymous email message, to be screened by me as a possible patient anonymously. Although he states he is not suicidal or homicidal, nor does he meet any of the criteria for possible involuntary hospitalization (by his own report), he remains extremely concerned about allowing this judgment to be made by someone (e.g. me) other than himself. He wants to talk about his concerns, learn more about treatment, and then “walk away” if that is what he decides. Do I have any ethical or professional considerations to make if I accept his terms?

Response by Dr. Barnett

Hi Chris. This is a very interesting situation. In addition to risk management and ethics issues and concerns, I suggest you also consider your personal comfort with this situation. If you are not comfortable with this arrangement you are under no obligation to participate in it. You may decide that it is not in you or this individual’s best interests to participate in such an arrangement of an anonymous e-mail screening.

I understand that you are describing a screening process to see if the individual might be an appropriate patient for you, or even if treatment is indicated. But, what happens if/when this individual shares about some significant issues, concerns, or risk factors? Your ability to respond appropriately has been severely restricted by the ‘rules’ imposed on you by this individual. While I understand he says he is not suicidal or homicidal, I also know that things are often not as simple as they first seem. I have to wonder why he is seeking treatment (and why he feels compelled to do it in this way!). It certainly doesn’t seem like a good start for a relationship built on trust. Also, if he is “extremely concerned about allowing this judgment to be made by someone… other than himself” then what is your role in the screening process? Are you screening him or is he just seeking information about you and the services you provide? I would also wonder why he couldn’t just walk away if he decided to after an in-person screening in which he shares about who he is and responds to all your questions.

While this may only be a ’screening’ I can see the potential for significant difficulties arising. Even though this is being termed a screening one must ask if you incur a professional obligation to this individual once you begin asking questions about his history, presenting problems, etc. I also wonder how open and honest he will be about all this and as a result, what kind of job you can do with the screening.

When faced with an ethical dilemma where we must decide between two possible courses of action, Choices A or B, I often find that the best course of action is Choice C, some other option (not one of the two initially presented to us). So, I suggest you consider the options and alternatives available to you, decide what your level of comfort is with this arrangement, clarify his goals and expectations and decide if this is something appropriate for you to offer, consider what unanticipated things might occur and if you want to be in that situation, and if proceeding as asked will be in this other individual’s best interest.

You may wish to explain to him why you are not able to participate in the process as he is requesting and explain to him what you are able to offer. While you may never hear from him again, you may also be surprised and find that he agrees to this alternative plan. If you do decide to proceed with this arrangement I suggest being very clear about the parameters of the relationship, what a ’screening’ is and that this does not constitute the establishment of a professional relationship, but that this is intended to help each of you decide if you want to enter a professional relationship.

If you do decide to proceed you should be able to articulate for yourself why you are doing this. Perhaps you sense how scared this person is and that you may be able to do some good for him with how you handle this screening process. But again, it is important to be very clear about what this is and isn’t, what the goals are, what your role is, and what the potential outcomes are. I would also keep in mind the potential risks for you should you participate as he dictates.

I hope this is of help. Good luck with this challenging situation. Jeff

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I have been treating a man with complex PTSD who started to see me after his transference feelings toward his previous psychotherapist became unmanageable. He sees me infrequently and has consulted with about 5 subsequent therapists who he reports trigger his trauma. He frequently emails me and occasionally sees me for a session but also sees other therapists. I have decided to allow him to do so even though I worry about his overall stability and therapist shopping. I sometimes feel as if I would like to tell him to discontinue treatment with me but feel that allowing him to utilize me this way provides some benefit. Is it OK to continue to allow him to see me infrequently and use email to maintain the attachment?

Response from Dr. Barnett

Jeffrey, Thanks for submitting the first question to Division 29’s new website feature “Ask the Ethicist.” You present a very interesting situation. I think it is very important that we not be constrained by the rigidity of weekly 50 minute long in-person psychotherapy sessions. Some clients benefit from being seen more frequently and some benefit from being seen less frequently. I think it really comes down to conducting a thoughtful assessment of each client’s clinical needs and responding accordingly. Also, what seems appropriate at one point in time my not be at another, so we must be flexible and willing to change our approach over time.

A lot has to do with your theoretical orientation and your assessment of the client’s treatment needs. While you should act consistently with both, you still have some flexibility with regard to how you proceed. The use of various technologies such as the telephone, e-mail, Skype, and others can be very appropriate for certain clients. These may be useful adjuncts to in-person treatment sessions. But, caution should be used if ever considering them as the sole means of providing treatment. Certainly e-mails miss the non-verbal cues so important to many communications. It is also important to ensure you know with whom you are communicating when using e-mail. Also, it may be important to use encryption software if privacy concerns exist.

I would also want to keep in mind our overarching goal of promoting each client’s autonomy and independence of us over time. While it should be a collaborative decision with your client, it is important to ensure that ongoing professional contacts are not promoting the client’s dependency on you. Relevant to this point is Standard 10.10(a), Terminating Therapy, of the APA Ethics Code, which states: “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.” (p. 1073). When unsure about the appropriateness of continued treatment, consultation with experienced colleagues (with the client’s appropriate consent) is recommended.

Relevant standards from the APA Ethics Code include those relevant to informed consent and confidentiality. Informed consent is important in that the client should understand all factors relevant to your work together that the average client might reasonably want to know prior to deciding on if they should participate. Further, all substantive changes to the treatment relationship and process over time necessitate an updating of the informed consent agreement. Clients should be informed of reasonably accessible options and alternatives to the treatment being provided along with all reasonably anticipated risks and benefits of each (to include not participating in treatment). We need to actively ensure that clients understand all this prior to proceeding with treatment. A discussion of confidentiality and any limits to it are especially important to include in the informed consent discussion when the use of technology is involved. While various technologies help clients to receive needed services in ways never before possible, they also bring risks and threats to privacy. Clients should understand these threats and psychotherapists should take necessary steps to minimize the risks of inappropriate breaches of confidentiality.

Providing psychotherapy or other services to a client who is also receiving services from other professionals is also an important issue to consider. At times, it is a client’s best interest for professionals to consult with each other, especially when trying to ensure they are not working at cross purposes. Standard 3.09, Cooperation With Other Professionals, of the APA Ethics Code is relevant here as well, stating: “When indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately (See also Standard 4.05, Disclosures)” (p. 1065). Of course, obtaining the client’s verbal and written consent to contact other professionals is important to do first.

When billing for services be sure the client understands the implications of using technologies and bill appropriately. For example, if a client’s insurance is paying for treatment but it only pays for in-person treatment sessions, the e-mail contacts may not be covered services. The client should know this up front. E-mail (and other technologies) sessions should never be billed as in-person sessions. But, brief e-mail contacts between sessions may prove very therapeutic for some clients. If fact, brief communications such as Twitter (under 140 characters per communication) may be quite helpful.

In summary, the answer to most ethical dilemmas is “It depends.” In this case, it depends on the client’s history and clinical needs; conducting a thorough assessment of the client’s treatment needs is essential. I would also want to know what the other professionals are offering as well. It is important to ensure that you are not working at cross purposes with these other professionals. Regularly reassessing the client’s treatment needs and the appropriateness of your treatment plan is important. As long as the client is fully informed and is benefiting from the continued treatment is may be quite appropriate to continue it.

When faced with ethical dilemmas one finds that there typically is no one correct answer. Rather, there are a number of important questions to ask, and depending on the answers to them, there may be a number of possible solutions, each bringing with them various pros and cons for us to consider. Thus, there likely are other reasonable perspectives on this situation and I very much welcome comments, reactions, and further discussion from all who read this post. Thanks and best wishes for your success with this client. Jeff

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