PSYCHOLOGY ETHICS IN THE VA: A Starting Point

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PSYCHOLOGY ETHICS IN THE VA A Starting Point

• Developed by the VAPTC - Clinical and Executive
  Committees and VISN 19 MIRECC

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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
  2025010364Fax [phone]
• Email IntegratedEthics_at_va.gov

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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

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How to Recognize Ethical Dilemmas

• Feelings of discomfort
• Conflict with values, personally and
  professionally
• Dissonance with virtues
• Dissonance with moral reasoning

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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?

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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

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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

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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
  

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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

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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 Peoples Rights Dignity
• Respect autonomy maintain professional
  boundaries preserve confidentiality privacy

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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

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Ethical Pitfalls

• Avoid ethical pitfalls by applying the APA
  Ethical Code Deborah Smiths 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

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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

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Ethics Question

• What should you do if you are scheduled to work
  with a Veteran you know personally?

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• 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 psychologists 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.

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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

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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

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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.

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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.

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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)

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Ethics Questions

• In what situations is confidentiality not
  guaranteed?
• How would you communicate this to the patient?

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Ethics Question

• If a patient asks you to send a report to another
  healthcare agency, what steps should you take?

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10 Ways to Avoid Ethical Pitfalls

• Respect Autonomy
• Informed consent
• Confidentiality
• Treatment length
• Billing practices
• Referrals

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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

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Ethics Questions

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

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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
  patients 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 patients condition or
  diagnosis that alters the initial consent

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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

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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 supervisees professional development
• Foster supervisees assessment of their
  competence
• Assess supervisee competence

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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)

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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

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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

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10 Ways to Avoid Ethical Pitfalls

• Abandonment Vs. Termination
• Termination utilizes competency
• Goals of beneficence patients autonomy
• Be aware when therapy is
• not benefiting the patient
• the patient may be harmed from continuing
  treatment
• the patient no longer needs therapy

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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.

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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

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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.

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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.

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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)?

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Risk Control Strategies

• Use informed consent professional disclosure
  forms
• Present information clearly check to make sure
  patient understands the information
• Uphold the VAs 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

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Additional Websites

• State of Colorado Department of Regulatory
  Agencies, Mental Health Licensing Section.
  http//www.dora.state.co.us/mental-health/index.ht
  m
• 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

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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