Ethical Risk Management
Preserving Our Clinical Integrity
By Zur Institute
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One of the worst professional or ethical violations is that of permitting current risk-management principles to take precedence over humane interventions. (Lazarus, 1994)
- We have been told, "Don't touch your clients!" "Minimize self-disclosure!" "Never venture outside the office with a client!" "Avoid bartering!" and "Avoid dual relationships at all costs!" These don'ts and many others whisper to us every time we emerge from one more risk management workshop or ethics and law seminar. They haunt us as we read with trepidation a bulletin from our malpractice carrier or review one more attorney's column in our professional organization's newsletter. Under the guise of risk management and self-protection, we are told, Beware! The slightest deviation from these ersatz commandments will set us on the 'slippery slope' to perdition.
- Risk management, the way it is often taught, means to avoid actions that may not look good in court or in licensing boards' hearings, regardless of their therapeutic value. It is my assertion that it is possible for us to protect ourselves while preserving our clinical and moral integrity. I believe we can touch our clients appropriately, self-disclose when helpful, barter when necessary, exchange gifts if it is therapeutic and engage in non-exploitative dual relationships without increasing the risk of being sued or losing our licenses.
Guidelines: Ethical Risk Management:
The complete guidelines are available at: zurinstitute.com/riskmanagement.html#guidelines.
- Always do whatever it takes to help clients while insuring that you do no harm to them in the process.
- Never exploit a client.
- Avoid situations where there are conflicts of interest.
- Always show respect for your clients, taking care never to humiliate them or assail their dignity.
- Place clients' welfare above your fear of boards, courts, ethics committees and attorneys.
- Remember - you are not paid to practice defensive medicine or risk management. Your duty is to help clients with the concerns and problems they are paying you to remedy.
- Intervene with your clients according to their problems, concerns, needs, gender, personality, situation, venue, environment and culture.
- Provide a safe and trusting place for healing and growth. Cold, distant, disconnected and punitive relationships do not promote healing and are likely to harm clients.
- Protect and respect your clients' privacy and confidentiality, unless by doing so you would fail to safeguard the client, community, etc., from harm or as required by the law.
- Intervene with your clients in a way that is most likely to be clinically effective. Do not intervene according to any dogma. In other words, different problems often require different clinical interventions.
- Be aware of the standard of care in your community. This is often referred to as the usual and customary professional standard of practice in the community.
- For each client develop an individualized treatment plan, zurinstitute.com/treatmentplanningcourse.html, which articulates:
- Presenting problems;
- Objectives of treatment;
- The means employed to achieve these objectives and the theory, research or philosophy that guide you in choosing the intervention/s;
- Ways to assess the effectiveness of the intervention.
- Keep good records. They are extremely important from clinical, ethical, legal and risk management points of view.
Make sure that your records include:
61 Essential Clinical Forms
- Informed consents and office policies, initial and updated treatment plans.
- Records of consultations, tests, etc.
- Releases or authorizations to release information.
- Important phone conversations, correspondence, emails and faxes to and from clients.
- Initial assessment and MSE.
- Details about termination, who initiated it and how it was carried out.
- When applied, referrals to medication evaluations or testing, other mental health professionals, twelve step or drug and alcohol rehabilitation programs, physicians, dietitians, physical training, attorneys and other resources.
- HIPAA compliance, when applicable.
- Consult with experts and educated colleagues for their input and assistance in complex and unusual cases. Document the consultation in your clinical notes.
- There are several types of cases or situations that merit our special attention and a greater degree of caution because historically they have presented challenges to therapists.
Some of these types of cases are:
- Child custody
- Repressed-Recovered memories
- Domestic violence and Child abuse
- There are several types of clients and Dx that merit our special attention. Some of these are:
- Borderline Personality
- Paranoid, Suicidal and Homicidal
- Clients with a history of litigation
- Multiple Personality and other dissociative disorders
- Never have sexual contact or sexual relationships with current clients. Be very careful and cautious before entering into sexual relationships with former clients. Seek ethical, clinical and legal advice before entering into such relationships.
- Handle clients' debts with sensitivity. Be very cautious before resorting to debt collection agencies, as it may trigger clients' complaints to licensing boards.
- Practice within the limits of your expertise and within your scope of practice as determined by your education, supervised training and clinical experience.
- Terminate thoughtfully and appropriately, zurinstitute.com/terminationcourse.html. Do not abandon your clients. Prepare for termination and offer referrals and follow-ups when appropriate. Document clearly: who initiated it, when, the nature of the discussion, potential referrals. Summarize the whole treatment in the records: what was achieved, to what extent, what was not achieved according to the last treatment plan.
- If the client terminates abruptly against your clinical judgment: Send a polite letter expressing your concerns in a clinically appropriate and sensitive way. Offer to continue therapy or to refer the client to another therapist. Add that you will be willing to help with the transition to another therapist if the client requests it.
- Collect and document collateral information when appropriate.
- Prevent your own burnout, zurinstitute.com/burnoutcourse.html, by creating balance in your life between professional work, familial, recreational, communal, political and/or spiritual activities.
- Be thoughtful about boundary crossings, such as home visits and other out-of-office experiences, gifts, bartering, touch and self-disclosure. Document these interventions and, when appropriate, include them in the treatment plans and ground them in a theoretical orientation.
- Be thoughtful about dual relationships, zurinstitute.com/drcourse.html. While many forms of dual relationships are unavoidable, ethical and potentially helpful, therapy never involves sexual or exploitative business relationships. Document all dual relationships; include a statement on dual relationships in the office policies and the informed consent; consult on complex cases. Avoid dual relationships that may result in a decrease in objectivity or clinical judgment.
- Pay attention to vicarious liability, such as renters or co-workers.
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