psychology ethics in the va - APPIC Shared Training Documents

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PSYCHOLOGY ETHICS IN
THE VA: A STARTING POINT
Developed by the VAPTC - Clinical and Executive
Committees and VISN 19 MIRECC
IMPORTANT RESOURCES



VA Integrated Ethics
http://vaww.ethics.va.gov
APA Ethics
http://www.apa.org/ethics
National Center for Ethics in Health Care
Veterans Health Administration (10E)
810 Vermont Avenue, NW Washington, DC 20420
Tel: 202–501–0364
Fax: 202–501–2238
Email: [email protected]
VA Integrated Ethics

Ethics – what is right or what should be done in
uncertain situations when values conflict.
 Healthcare
professionals should consider ethics in every
decision
 Share ethical commitment with your peers, supervisors,
and organization
 Consult with supervisor and VHA ethical consultation
service
How to Recognize
Ethical Dilemmas




Feelings of discomfort
Conflict with values, personally and professionally
Dissonance with virtues
Dissonance with moral reasoning
Self Awareness Exercise
What are your personal values and
virtues?
 How do these values and virtues coincide
with your professional values?
 What are your professional motivations?

Ethical Decision-Making

Ethical Decisions
Identify the situation
 Gather all relevant information
 Identify ethical standards & legal policies
 Develop and weigh alternative approaches using
ethical standards & legal policies
 Consult with professionals
 Implement the approach, evaluate the outcome

Ethical Question:

a)
b)
c)
d)
e)
As an intern, you are convinced that your supervisor is
encouraging his trainees to participate in unethical
behavior, you would:
First discuss the matter with the supervisor
Report the supervisor to the director of the
department
Ignore the situation
Report the situation to the ethics committee of the state
professional association
Consult with a trusted professional
Adapted from Issues and Ethics in the Helping Professions,
Corey, Corey, & Callanan, 2003
Using Consultation for
Ethics in the VA

VA Integrated Ethics provides an ethics consultation
service to help with research regarding an ethical
dilemma.
Example 1: Are Veterans with PTSD considered a
vulnerable population in research?
 Example 2: What are the ethical challenges of
coordinating care between the VA & Department of
Defense?
 Investigate these examples using this website:
http://vaww.ethics.va.gov/resources/siteindex.asp

APA Code of Ethics



Provides principles and standards to guide
psychologists professional and scientific work
APA members should comply with the standards of the
Ethics Code & the rules & procedures used to enforce
them
The Ethics Code applies to psychologist activities
including administration, education, professional,
policy & scientific activities
Adapted from APA 2002
APA Code of Ethics

5 Principles:
1.
Beneficence & Nonmaleficence

2.
Fidelity & Responsibility

3.
Maximize benefits & minimize harm through accuracy, honesty &
truthfulness
Justice

5.
Develop trust; accept responsibility of work; uphold professional
standards of conduct
Integrity

4.
Do Good; Avoid Harm
Exercise competence & reasonable judgment
Respect for People’s Rights & Dignity

Respect autonomy; maintain professional boundaries; preserve
confidentiality & privacy
Adapted from APA 2002
APA Code of Ethics

10 Standards
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Resolving Ethical Issues
Competence
Human Relations
Privacy & Confidentiality
Advertising & Public Statements
Record Keeping & Fees
Education & Training
Research & Publication
Assessment
Therapy
Adapted from APA 2002
Ethical Pitfalls

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Avoid ethical pitfalls by applying the APA Ethical
Code & Deborah Smith’s 10 pointers:
Understand Multiple Relationships
Protect Confidentiality
Respect Autonomy
Know Supervisory Responsibilities
Identify Client & Role
Document
Practice in Area of Expertise
Abandonment vs. Termination
Stick to the Evidence
Be Accurate in Billing
From 10 Ways Practitioners Can Avoid Frequent Ethical Pitfalls,
Smith, 2003
10 Ways to Avoid Ethical Pitfalls
Understand what constitutes a multiple
relationship.
A multiple relationship occurs when:
1.
Participating in two or more relationships or roles with
another person
A multiple relationship can:
 Happen simultaneously or at different times
 Cause harm or be exploitative

Ethics Question:

What should you do if you are scheduled to work
with a Veteran you know personally?
APA Ethics Code on Multiple Relationships
“A psychologist refrains from entering into a multiple
relationship if the multiple relationship could
reasonably be expected to impair the
psychologist’s objectivity, competence, or
effectiveness in performing his or her functions as
a psychologist, or otherwise risks exploitation or
harm to the person with whom the professional
relationship exists.”
10 Ways to Avoid Ethical Pitfalls
Multiple relationships (continued)

What does this mean?





Power differentials
Duration of relationships
Sexual relationships are never permissible
Gifts & bartering
Supervisor/supervisee
Ethical Question:

a)
b)
c)
d)
e)
If a patient evidenced strong feelings of attraction
or dislike for me, I think I would:
Help the client work through these feelings and
understand them.
Enjoy these feelings if they were positive.
Refer my patient to another therapist.
Direct sessions into less emotional areas.
Other:
Adapted from Issues and ethics in the helping professions
Corey, Corey, & Callanan, 2003
Ethical Question:

a)
b)
c)
d)
A sexual relationship between a former patient and
a psychologist is:
Ethical if the patient initiates it.
Ethical only 2 years after termination of therapy.
Ethical only when client and therapist discuss the
issue and agree to the relationship.
Never ethical, regardless of the time that has
elapsed.
Adapted from Issues and ethics in the helping professions
Corey, Corey, & Callanan, 2003
10 Ways to Avoid Ethical Pitfalls
2.


Confidentiality
Psychologists are asked to provide information
about their patients to family members, other
healthcare professionals, and other agencies.
APA Ethics Code states that only the minimum
information necessary should be disclosed in order
to provide needed services, obtain appropriate
consultations, protect the client, psychologist or
others from harm, or obtain payment for services
from a client.
10 Ways to Avoid Ethical Pitfalls
Confidentiality
Discuss limits of confidentiality with patient
Protecting confidentiality by safeguarding confidential
records
Know state and federal laws




HIPAA



The Privacy Rule sets Federal standards for protecting the
privacy of individually identifiable health information and
identifies the rights of all parties involved.
http://www.hhs.gov/ocr/hipaa
Know organizational policies (e.g.,VA Handbook 1605.1)
Ethics Questions:

In what situations is confidentiality not guaranteed?

How would you communicate this to the patient?
Ethics Question:

If a patient asks you to send a report to another
healthcare agency, what steps should you take?
10 Ways to Avoid Ethical Pitfalls
3.
Respect Autonomy





Informed consent
Confidentiality
Treatment length
Billing practices
Referrals
Informed Consent

Competence


Disclosure


Clearly discuss confidentiality, privacy, treatment options, documentation
procedures, and emergency contact information
Voluntariness


If you are a trainee under supervision, this must be disclosed to the
patient (e.g., need to explain your role and goal of the interaction)
Patient Understanding


Practice only within your limits of expertise, experience & training
The patient has the right to terminate therapy at any time, therapy is a
voluntary service
Authorization

Obtain documented authorization of patient consent
From Kitchner 1992
Ethics Questions:

Regarding disclosure, when should you (or the VA)
tell patients that a mistake was made in the course
of their treatment?
Informed Consent in the VA




All VHA patients have the right to accept or refuse any
medical treatment or procedure.
All VHA patients must provide voluntary, informed
consent for any treatment/procedure, or if the patient
lacks decisional-making capacity, the patient’s
authorized surrogate.
Informed consent may cover a one-time or multiple-visit
treatment.
New consent must be obtained if there is a deviation or
change in the treatment plan and/or there is a change
in the patient’s condition or diagnosis that alters the
initial consent
From VHA Handbook 1004.1
Informed Consent in the VA

Informed consent process ( Handbook 1004.1)
 Informing
the patient
 Provide
information clearly and in a language
understandable by the patient regarding treatment details,
options/alternatives, risks & benefits
 Ensure the patient understands and encourage the patient to
ask questions
 Promote
voluntary decision-making
 Document the process
From VHA Handbook 1004.1
10 Ways to Avoid Ethical Pitfalls
4.
Know Supervisory Responsibilities



a)
b)
c)
d)
Inform patients about supervision
Utilize VA supervisory agreement form
Goals of supervision:
Protect the patient
Facilitate supervisee’s professional development
Foster supervisee’s assessment of their competence
Assess supervisee competence
10 Ways to Avoid Ethical Pitfalls
5.
Identify Client and Role



Who, What, Where
Compensation and pension evaluations &
confidentiality
Special confidentiality limits (e.g. Tricare insurance)
10 Ways to Avoid Ethical Pitfalls
6.
Documentation
Contact log, history, dates, impressions, informed
consent, follow-up contact
NEVER alter a record after the fact




Append information to the health record per local policy
Record only pertinent information as related to the
treatment and health services
10 Ways to Avoid Ethical Pitfalls
7.
Practice ONLY in Area of Expertise
Competency



Knowledge, Skills & Abilities
Be aware of your own impairment/limitations

Stay informed



Internal or external factors may interfere with your
knowledge, skills and abilities to appropriately treat patients
Continue professional education through seminars,
conferences, workshops, research
Know when to refer
10 Ways to Avoid Ethical Pitfalls
8.



Abandonment Vs. Termination
Termination utilizes competency
Goals of beneficence & patient’s autonomy
Be aware when therapy is:

not benefiting the patient

the patient may be harmed from continuing treatment

the patient no longer needs therapy
Too Soon
Therapist
Therapist &
Client
Client
Just Right
Too Late
Abandonment
Perfection!
Dependence
Table adapted from Anderson & Handelsman 2010
Ethical Question

a)
b)
c)
A therapist should terminate therapy with a patient
when:
The patient decides to terminate.
The therapist decides to terminate.
The patient is not benefiting from treatment.
Adapted from Issues and ethics in the helping professions
Corey, Corey, & Callanan, 2003
10 Ways to Avoid Ethical Pitfalls
9.
Stick to the Evidence



Be mindful of what you do and do not know
Know the referral question
Evaluate, interview and assess thoroughly
Be Accurate in Billing
10.

Document every session and contact accurately to
ensure proper agency billing
Five Principles for Research Ethics
APA article by Deborah Smith
Discuss intellectual property frankly
Be conscious of multiple roles
Follow informed consent rules
Respect privacy & confidentiality
Utilize ethics resources
1.
2.
3.
4.
5.

The Belmont Report. Released by the National Commission for the Protection of Human Subjects of Biomedical
and Behavioral Research in 1979, the report provided the ethical framework for ensuing human participant
research regulations and still serves as the basis for human participant protection legislation (see Further
Reading).

APA's Ethics Code, which offers general principles and specific guidance for research activities, available at
www.apa.org/ethics.
Risk Management

By focusing on identifying, evaluating, and treating
problems that may cause undue harm to the patient,
such preventative measures may reduce the practice
of unethical behavior, minimize litigation, and
reduce the chance of malpractice.
Adapted from Issues and ethics in the helping professions
Corey, Corey, & Callanan, 2003
Research Ethics Questions:


How do you know that a research subject
understands the informed consent?
How do you decide authorship hierarchy (i.e., who
should be listed first)?
Risk Control Strategies













Use informed consent & professional disclosure forms
Present information clearly & check to make sure patient understands the
information
Uphold the VA’s standards of care
Keep up-to-date on ethical and legal standards
Explain diagnosis, treatment plan, and risks and benefits of treatment
Continue professional education
Monitor self-competency
Refer patients when necessary
Carefully document patient interactions
Avoid multiple relationships, or consult with supervisor if unavoidable
Know how to assess & intervene when patient poses danger to self or others
Know limits of confidentiality and clearly communicate these to the patient
Treat your patients with respect and develop a trusting relationship
From Issues and Ethics in the Helping Professions, Corey, Corey,
& Callanan, 2003
Additional Websites:





State of Colorado Department of Regulatory Agencies, Mental Health
Licensing Section. http://www.dora.state.co.us/mental-health/index.htm
United States Office of Government Ethics:
http://www.usoge.gov/home.html
Dept. of Veterans Affairs - Public and Intergovernmental Affairs:
http://www1.va.gov/opa/
The Center for Ethics and Human Rights:
http://www.ana.org/ethics/elinks.htm
Biomedical and Health Care Ethics Resources:
http://www.ethics.ubc.ca/resources/biomed
References





American Psychological Association. (2002). American Psychological Association ethical principles of
psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code
Anderson, S.K., & Handelsman, M.M. (2010). Ethics for psychotherapists and counselors: A proactive
approach. West Sussex, UK: Wiley-Blackwell.
Campbell, L.., Vasquez, M., Behnke, S., Kinscherff, R. (2009). APA Ethics Code Commentary and Case
Illustrations. Washington, D.C.: American Psychological Association.
Corey, G., Corey, M.S., & Callanan, P. (2003). Issues and ethics in the helping professions (6th ed.).
Pacific Grove, CA: Brooks/Cole.
Kitchner, K.S. (2000). Foundations of ethical practice, research, and teaching in psychology. Mahwah,
NJ: Lawrence Erlbaum Associates, Inc.

Smith, D. (2003). 10 ways practitioners can avoid frequent ethical pitfalls. APA Monitor, 34, 50.

Smith, D. (2003). Five principles for research ethics. APA Monitor, 34, 56.

VHA Handbook 1004.1

VHA Handbook 1605.1

VHA Integrated Ethics
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