PSYCHOLOGY ETHICS IN THE VA: A Starting Point

1. PSYCHOLOGY ETHICS IN THE VA: A Starting Point Developed by the VAPTC - Clinical and Executive Committees and VISN 19 MIRECC

2. 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 20420Tel: 202–501–0364Fax: 202–501–2238 Email: IntegratedEthics@va.gov

3. 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

4. How to Recognize Ethical Dilemmas • Feelings of discomfort • Conflict with values, personally and professionally • Dissonance with virtues • Dissonance with moral reasoning

5. 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?

6. 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

7. Ethical Question: • 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

8. 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

9. 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

10. APA Code of Ethics • 5 Principles: • Beneficence & Nonmaleficence • Do Good; Avoid Harm • Fidelity & Responsibility • Develop trust; accept responsibility of work; uphold professional standards of conduct • Integrity • Maximize benefits & minimize harm through accuracy, honesty & truthfulness • Justice • Exercise competence & reasonable judgment • Respect for People’s Rights & Dignity • Respect autonomy; maintain professional boundaries; preserve confidentiality & privacy Adapted from APA 2002

11. APA Code of Ethics • 10 Standards • Resolving Ethical Issues • Competence • Human Relations • Privacy & Confidentiality • Advertising & Public Statements • Record Keeping & Fees • Education & Training • Research & Publication • Assessment • Therapy Adapted from APA 2002

12. Ethical Pitfalls • 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

13. 10 Ways to Avoid Ethical Pitfalls • Understand what constitutes a multiple relationship. A multiple relationship occurs when: • 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

14. Ethics Question: • What should you do if you are scheduled to work with a Veteran you know personally?

15. 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.”

16. 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

17. Ethical Question: • 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

18. Ethical Question: • 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

19. 10 Ways to Avoid Ethical Pitfalls • 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.

20. 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)

21. Ethics Questions: • In what situations is confidentiality not guaranteed? • How would you communicate this to the patient?

22. Ethics Question: • If a patient asks you to send a report to another healthcare agency, what steps should you take?

23. 10 Ways to Avoid Ethical Pitfalls • Respect Autonomy • Informed consent • Confidentiality • Treatment length • Billing practices • Referrals

24. Informed Consent • Competence • Practice only within your limits of expertise, experience & training • Disclosure • 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 • Clearly discuss confidentiality, privacy, treatment options, documentation procedures, and emergency contact information • Voluntariness • 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

25. Ethics Questions: • Regarding disclosure, when should you (or the VA) tell patients that a mistake was made in the course of their treatment?

26. 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

27. 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

28. 10 Ways to Avoid Ethical Pitfalls • Know Supervisory Responsibilities • 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

29. 10 Ways to Avoid Ethical Pitfalls • Identify Client and Role • Who, What, Where • Compensation and pension evaluations & confidentiality • Special confidentiality limits (e.g. Tricare insurance)

30. 10 Ways to Avoid Ethical Pitfalls • 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

31. 10 Ways to Avoid Ethical Pitfalls • Practice ONLY in Area of Expertise • Competency • Knowledge, Skills & Abilities • Be aware of your own impairment/limitations • Internal or external factors may interfere with your knowledge, skills and abilities to appropriately treat patients • Stay informed • Continue professional education through seminars, conferences, workshops, research • Know when to refer

32. 10 Ways to Avoid Ethical Pitfalls • 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 Table adapted from Anderson & Handelsman 2010

33. Ethical Question • 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

34. 10 Ways to Avoid Ethical Pitfalls • 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 • Document every session and contact accurately to ensure proper agency billing

35. Five Principles for Research EthicsAPA article by Deborah Smith • Discuss intellectual property frankly • Be conscious of multiple roles • Follow informed consent rules • Respect privacy & confidentiality • Utilize ethics resources • 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.

36. 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

37. 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)?

38. 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

39. 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

40. 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