Managing Risk Under the New APA Ethics Code

1. Managing Risk Under the New APA Ethics Code Gerald P. Koocher, Ph.D., ABPP

2. Ethics vs. Risk Management The 4 D’s: Dereliction of Duty leading Directly to Damages • When does a professional duty apply? • What constitutes dereliction? • How can one demonstrate direct causation? • How can we measure damages?

3. Psychologists are trained as behavioral scientists. We believe that an individual applying rigorous experimental methods can discover significant truths within ranges of statistical certainty. Lawyers are educated as advocates. Lawyers believe that the search for truth is best conducted in a vigorous adversarial cross-examination of the facts. The Culture Gap Between Psychologists and Lawyers

4. Behavioral scientists seldom give simple dichotomous answers to questions. We prefer to use probabilities, ranges, norms, and continua that reflect the complexity of human differences. Lawyers are taught that the facts must be “tried” or weighed. Clear, precise, unambiguous decisions must result; bright lines and clear dichotomies are valued and expected. The Culture Gap

5. We should empathize with our clients and show them unconditional positive regard. Little progress will occur in our work with clients if we do not like and respect each other. We constantly collect data and try to ask all the important and sensitive questions. Attorneys believe that they can (and must) at times defend people they detest. Attorneys may choose not to ask their clients certain questions (e.g., “Did you do it?”) in order to defend them vigorously. The Culture Gap

6. Levels of ProofPreponderance of evidence (51%)Clear and convincing evidence (75%)Beyond a reasonable doubt (95%)

7. Multiple Relationships Standard 3.05a provides improved clarity and definition as to when multiple relationship occurs: • A psychologist is in a professional role with a person, and • Simultaneously is in another role with the same person, or • Simultaneously is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or • The psychologist promises to begin another relationship in the future with the person or a person closely associated with or related to the person.

8. Multiple Relationships What to do? • Refrain from entering into a multiple relationship if that 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 risk exploitation or harm to the person with whom the professional relationship exists.

9. Multiple Relationships Not every multiple relationship is risky. • Relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.

10. Protections for Graduate Students in Therapy Standards 7.02 Descriptions of Education and Training Programs • Provide current and accurate description of the program content (including participation in required course- or program-related counseling, psychotherapy, experiential groups, consulting projects, or community service), training goals and objectives, stipends and benefits, and requirements that must be met for satisfactory completion of the program. Make these data readily available.

11. Protections for Graduate Students in Therapy Standard 7.04 Student Disclosure of Personal Information • Do not require students or supervisees to disclose personal information in course or program related activities, either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, peers, and spouses or significant others except if • (1) the program or training facility has clearly identified this requirement in its admissions and program materials or • (2) the information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training- or professionally related activities in a competent manner or posing a threat to the students or others.

12. Protections for Graduate Students in Therapy Standard 7.05 Mandatory Individual or Group Therapy • When individual or group therapy is a program or course requirement, psychologists responsible for that program allow students in undergraduate and graduate programs the option of selecting such therapy from practitioners unaffiliated with the program. (Linked to 7.02) • Faculty who are or are likely to be responsible for evaluating students’ academic performance do not themselves provide that therapy. (Linked to 3.05)

13. IRB Approval Inclusion Standard 8.01 Institutional Approval • When institutional approval is required, psychologists provide accurate information about their research proposals and obtain approval prior to conducting the research. They conduct the research in accordance with the approved research protocol.

14. Informed Consent Requirements for experimental research Standard 8.02(a) Informed Consent to Research • Eight key points in obtaining informed consent: (1) Explain purpose of the research, expected duration, and procedures; (2) Note the right to decline to participate and to withdraw once participation has begun; (3) Describe foreseeable consequences of declining or withdrawing;

15. Informed Consent Requirements for experimental research (4) Describe factors that might reasonably influence willingness to participate (e.g.,potential risks, discomfort, or adverse effects); (5) Note any prospective research benefits; (6) Describe limits of confidentiality; (7) List incentives for participation; and (8) Advise whom to contact with questions about the research and participants’ rights, provide opportunity for the prospective participants to ask questions and receive answers.

16. Informed Consent Requirements for experimental research Standard 8.02 (b)Clarifications to research participants owed at the outset of the research: (1) experimental nature of the treatment; (2) services that will or will not be available to the control group(s) if appropriate; (3) means by which people are assigned to treatment and control groups; (4) available treatment alternatives if an individual does not wish to participate in the research or wishes to withdraw once a study has begun; and (5) compensation for or monetary costs of participating including, if appropriate, whether reimbursement from participants or a third-party payers will be sought.

17. Publication Credit Protections for Students Standard 8.12(c) • Under normal circumstances, a student is listed as principal author on any multiple-authored article that is substantially based on the student’s doctoral dissertation. Faculty advisors discuss publication credit with students as early as feasible and throughout the research and publication process as appropriate.

18. Assessment Standards Standard 9.01 Bases for Assessments (a) Base the opinions on information and techniques sufficient to substantiate the findings. (b) Except as noted in (c), provide opinions of the psychological characteristics of individuals only after they have conducted an examination of the individuals adequate to support their statements or conclusions. (c) When conducting record reviews or consulting and supervising and an individual examination is not warranted or necessary to render an opinion, psychologists note the sources of data on which conclusions and recommendations are based.

19. Release of Test Data Standard 9.04 • (a) Test data refers to raw and scaled scores, patient responses to test questions or stimuli, and psychologists’ notes and recordings concerning patient statements and behavior during an examination. Those portions of test materials that include client/patient responses are included in the definition of test data. • Pursuant to a client/patient release, psychologists provide test data to the client/patient or other persons identified in the release.

20. Release of Test Data Standard 9.04(continued) • Psychologists may refrain from releasing test data to protect a patient or others from substantial harm or misuse or misrepresentation of the data or the test, recognizing that in many instances release of confidential information under these circumstances is regulated by law. • (b) In the absence of a release, psychologists provide data only as required by law or court order.

21. Maintaining Test Security Standard 9.11 • The term test materials refers to manuals, instruments, protocols, and test questions or stimuli and does not include test data as defined in Standard 9.04, “Release of Test Data.” • Psychologists make reasonable efforts to maintain the integrity and security of test materials and other assessment techniques consistent with law and contractual obligations, and in a manner that permits adherence to the ethics code.

22. Informed Consent in Therapy Standard 10.01(b) • When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation.

23. When to Terminate Therapy Standard 10.10 (a) Psychologists terminate therapy when it becomes clear that the patient no longer needs the service, is unlikely to benefit, or is being harmed by continued service. (b) Psychologists may terminate therapy when threatened or otherwise endangered by the patient or another person with whom the patient has a relationship. (c) Except where precluded by the actions of patients or third-party payers, prior to termination psychologists provide pretermination counseling and suggest alternatives as appropriate.

24. How About HIPAA?AKA: 45 C.F.R.160 HIPAA connections • Notification on limits on confidentiality • Requirement of releases • Information and records to clients • Address electronic transmission throughout • Example: 4.02(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.

25. Does Forensic Practice Fall Under HIPAA ? NO!Forensic work is not health care delivery and does not involve PHI. • Not done for purposes of treatment • Legal purpose • Court-ordered or mandated • Not covered by third parties

26. Does Forensic Practice Fall Under HIPAA ? YES! Forensic work may involve health care delivery and PHI. • A diagnosis is often offered • Courts may mandate “treatment” • Incarcerated people may be treated • Treating experts may be witnesses • Roles may change (e.g., from evaluator to treating clinician)

27. Forensic Practice Under HIPAA ?Solutions • Rigorous notice • Informed consent • Secure transmission • Clear court orders • Detailed re-consent for any role changes

28. Other Changes • Statement that aspirational language does not create an “obligation.” • Forensic section eliminated and content spread throughout. • Prohibition on unfair discrimination against people filing or responding to ethics complaints • As for reasonable steps to avoid using interpreters with multiple patient roles.