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