What Should I Do? – Ethical Dilemmas in EAP Work Paul Clavelle September 6, 2018 Survey class workshops/classes policies, procedures, and contracts

Introduction – Format for Today First some introductory comments, then: The standards and documents that guide our ethical decision-making. Assumption: You are familiar with them. The most common ethical violations. The EAPA ethical decision-making model. Discussion of cases illustrating some of the major types of ethical dilemmas we and other EAP professionals face. Scenarios. (Yours are the best.)

Common criticisms of ethics/legal workshops Boring Discussion > lecture Not relevant to my practice Topics all EAP-related; please feel free to contribute your own dilemmas and experiences Anxiety-provoking Statistics Not solo private practice or long-term therapy Your organization’s policies and procedures Opportunity to consult (including EAPA) Common-sense preventive measures Jot down ethical dilemmas you have faced and preventive measures you have taken

Willful Violations of Ethics vs Ethical Dilemmas Violations: When you know it is wrong, and you do it anyway. Less common Examples: fraud, having sex with someone you are counseling Dilemmas: When it is not clear what is ethical , i.e., the right thing to do More common Usually because two ethical principles are in conflict E.g., Confidentiality and duty to protect

Some Caveats My personal experience is almost all “internal.” When all is said and done, there may well be disagreements, since we are talking values. We can’t avoid legal issues. They are part of ethics. But take all comments made about the law this morning with a grain of salt. Ask for documents before next slide.

What Informs/Influences Professional Ethical Decisions? Laws, especially state laws State BoE Code of Ethics for Your Profession Your Professional Association(s) Code of Ethics The EAPA Code of Ethics Your EAP’s Policies and Procedures Your Contractual Agreements Your Personal Beliefs, Feelings, and Experiences

To Whom Are We Responsible To Whom Are We Responsible? The Framework of the EAPA and NASW Code of Ethics To our colleagues and other professionals To employees who are our clients To employers or work organizations To vendors and providers As professionals In conducting research To the EAP profession and the broader society

Question What do we think are the most common ethical violations committed by mental health professionals?

The Most Common Ethics Violations, As Reported by NASW 56% are “boundary infractions” 72% of these involved sexual relations Others Fraud Failure to refer or transfer (practicing beyond one’s competence) Confidentiality breaches Inadequate record keeping Conflict of interest Failure to take steps to prevent suicide

Most Common Ethical Complaints Filed with the APA Sexual misconduct with adult clients 29% Insurance/fee problems 21% Child Custody evaluations 10% “Other” professional misconduct 10% Sexual misconduct with minors 7% Nonsexual dual relationships 7% Practicing outside of competency 5% Inappropriate follow up/termination 5%

Most Common Ethical Complaints to State Mental Health Licensing Boards Practicing without a license 29% Sexual relationship with a client 20% Poor standard of care 15% Inappropriate fee assessment 12% Dual relationships 7% Breach of confidentiality 5% Failure to report abuse 4% Nationally, 66% of all complaints were determined to be not serious enough for formal investigation.

The EAPA Ethical Decision-Making Model 1. Consider the potential ethical issues in the situation. State the dilemma as clearly as you can. What are the competing values or interests? What are my personal values on this issue and do they complicate the situation? What ethical guidelines apply to this issue? You may decide there is no ethical dilemma.

The EAPA Ethical Decision-Making Model 2. Consider: Who has a legitimate interest in this situation? Who stands to be affected by my decision? Individual client(s)? Work organization? Others directly or indirectly involved? Society? Myself? Limits of “Who Is the Client?”

The EAPA Ethical Decision-Making Model 3. Consider all possible courses of action, and ask which choices benefit... The individual client? The work organization? Others directly or indirectly involved? Society? Myself? 4. Make a decision.

Some Additional Considerations Ask: Is the issue one of ethics, law, and/or policy/procedure? E.g., “ancient” child abuse reporting; threats against others. Ask: Do I need more information? E.g., reread a law or policy Gather more clinical information Ask: Am I treating this client differently in any way? If so, why? Transference? Counter-transference?

* Consult * * Inform * * Document * If necessary and possible, consult with a trusted colleague (supervisor, if you have one). Inform all people and organizations who need to be informed, and only them. Document what you did (or didn’t do) and why. Mention EAPA’s Panel of Ethics Experts

The Major Topics We Will Discuss Today Boundary Issues Dual/Multiple Relationships Conflicts of Interest Professional Relationships Teleservices Informed Consent Confidentiality Our Obligations to the Greater Society Others?

Boundary Issues All healthy relationships require boundaries. This is especially true in relationships, such as the psychotherapeutic relationship, where one person has, or can be perceived as having, more power, authority, or ability to influence. Boundaries protect the client from maleficence, incompetence, or abuse of authority, and they protect the therapist from complaints and litigation. Some boundary issues are clear-cut. Others are not.

Boundary Issues What preventive measures do you have in place?

Dual/Multiple Relationships Definition: You are in a dual/multiple relationship when you are in a professional relationship with a client, and have been, are now, or will be in the future in any other type of relationship with that person or with somebody or some organization closely related to or affiliated with that person. E.g., alternative dispute resolution. Roles in Army and Police Dept.

Dual/Multiple Relationships – NASW’s Recommendations Explain to everyone involved the dilemma as you see it, including the possible downside of the dual/multiple relationship. If the client wishes to proceed anyway, consult with a colleague first before making a final decision. Do what is in the best interest of the client and anybody else involved. Document as appropriate.

Dual/Multiple Relationships What preventive measures do you have in place?

Conflict of Interest Definition: A situation in which you have multiple interests (financial or otherwise), one of which could possibly unduly influence or perhaps even corrupt your motivation or behavior concerning a client or other person or organization toward whom you have some responsibility.

Conflict of Interest What preventive measures do you have in place in your work setting?

Relationships with Colleagues These are often among the toughest dilemmas, in my experience.

Teleservices “EAP professionals will ensure that the technology utilized to provide services to clients in remote locations will not allow inadvertent breach of client information.” “When providing telephonic, online or other remote services, professionals will have received training specific to working with clients via the specific method of service delivery.”

Teleservices Do you provide teleservices? If so, do you have a policy in place? Does it conform to state law and your profession’s guidelines?

Confidentiality Definition: Confidentiality in a professional relationship is the client’s right to have information shared in privacy with the professional remain private, within the limits of a written, signed informed consent agreement that specifies any circumstances under which the privacy of a communication may be breached.

Informed Consent Definition: A process for obtaining permission before providing professional services to a client. The permission must be based on a clear appreciation and understanding by the client of the facts, implications, and consequences of any action on your part or theirs. The Maryland Code of Ethics for Social Workers adds: A licensee shall “apprise the client of the risks, opportunities, and obligations associated with services available to the client.” Distribute scenarios

Confidentiality Informed consent form signed? Confidentiality rules in writing and understood by all involved? Records secure – hard and soft copies?

Informed Consent Client rights, e.g., appeal, grievance Limits to confidentiality Ownership and disposition of records Access to records Financial arrangements Related issue: Do all stakeholders understand and agree to the limits ahead of time? E.g., OGC

Duty to Warn/Protect What is the difference? In Maryland, which duty do we have? Md. COURTS AND PROCEEDINGS Code Ann. § 5- 609 (2013)

Maryland’s Duty to Protect Law -1 When does it apply? A client communicates to the counselor intent to harm another person; The client identifies one or more specific persons as intended victims; and The counselor assesses the client’s threat as valid, i.e., believes that there is a reasonable likelihood that the client will carry out the threat.

Maryland’s Duty to Protect Law -2 What must the counselor do to discharge his/her duty? 1. Seek civil commitment, OR 2. formulate a treatment plan to eliminate the threat, OR 3. Inform law enforcement in a reasonable and timely manner. Immunity is granted for disclosure of confidential information.

Questions, comments, scenarios?