psychology ethics in the va: a starting point developed by the vaptc - clinical and executive...
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PSYCHOLOGY ETHICS IN THE VA: A STARTING POINTDeveloped by the VAPTC - Clinical and Executive Committees and VISN 19 MIRECC
IMPORTANT RESOURCES
VA Integrated Ethics http://vaww.ethics.va.gov
APA Ethicshttp://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
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:
As an intern, you are convinced that your supervisor is encouraging his trainees to participate in unethical behavior, you would:
a) First discuss the matter with the supervisorb) Report the supervisor to the director of the
departmentc) Ignore the situationd) Report the situation to the ethics committee
of the state professional associatione) 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
Do Good; Avoid Harm
2. Fidelity & Responsibility Develop trust; accept responsibility of work; uphold
professional standards of conduct
3. Integrity Maximize benefits & minimize harm through accuracy,
honesty & truthfulness
4. Justice Exercise competence & reasonable judgment
5. Respect for People’s Rights & Dignity Respect autonomy; maintain professional boundaries;
preserve confidentiality & privacyAdapted from APA 2002
APA Code of Ethics
10 Standards1. Resolving Ethical Issues2. Competence3. Human Relations4. Privacy & Confidentiality5. Advertising & Public Statements6. Record Keeping & Fees7. Education & Training8. Research & Publication9. Assessment10. Therapy
Adapted from APA 2002
Ethical Pitfalls
Avoid ethical pitfalls by applying the APA Ethical Code & Deborah Smith’s 10 pointers:
1. Understand Multiple Relationships
2. Protect Confidentiality
3. Respect Autonomy
4. Know Supervisory Responsibilities
5. Identify Client & Role
6. Document
7. Practice in Area of Expertise
8. Abandonment vs. Termination
9. Stick to the Evidence
10. Be Accurate in BillingFrom 10 Ways Practitioners Can Avoid Frequent Ethical Pitfalls,
Smith, 2003
10 Ways to Avoid Ethical Pitfalls
1. Understand what constitutes a multiple relationship.
A multiple relationship occurs when: Participating in two or more relationships
or roles with another personA 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:
If a patient evidenced strong feelings of attraction or dislike for me, I think I would:
a) Help the client work through these feelings and understand them.
b) Enjoy these feelings if they were positive.c) Refer my patient to another therapist.d) Direct sessions into less emotional areas.e) Other:
Adapted from Issues and ethics in the helping professions Corey, Corey, & Callanan, 2003
Ethical Question:
A sexual relationship between a former patient and a psychologist is:
a) Ethical if the patient initiates it.b) Ethical only 2 years after termination of
therapy.c) Ethical only when client and therapist
discuss the issue and agree to the relationship.
d) Never ethical, regardless of the time that has elapsed.
Adapted from Issues and ethics in the helping professionsCorey, 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
From Kitchner 1992
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
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
From VHA Handbook 1004.1
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
Informed Consent in the VA
From VHA Handbook 1004.1
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
10 Ways to Avoid Ethical Pitfalls
4. Know Supervisory Responsibilities Inform patients about supervision Utilize VA supervisory agreement form
Goals of supervision: a) Protect the patientb) Facilitate supervisee’s professional
developmentc) Foster supervisee’s assessment of their
competenced) 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
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
10 Ways to Avoid Ethical Pitfalls
Table adapted from Anderson & Handelsman 2010
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 Just Right Too Late
Therapist Abandonment
Therapist & Client
Perfection!
Client Dependence
Ethical Question
A therapist should terminate therapy with a patient when:
a) The patient decides to terminate.b) The therapist decides to terminate.c) The patient is not benefiting from
treatment.
Adapted from Issues and ethics in the helping professionsCorey, 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
10. Be Accurate in Billing Document every session and contact
accurately to ensure proper agency billing
Five Principles for Research EthicsAPA article by Deborah Smith1. Discuss intellectual property frankly2. Be conscious of multiple roles3. Follow informed consent rules4. Respect privacy & confidentiality5. 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.
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
From Issues and Ethics in the Helping Professions, Corey, Corey, & Callanan, 2003
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
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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