Advanced Ethics for Counseling Professionals

I'd like to welcome everybody to today's live presentation on ethics for counseling professionals. I'm your host, Dr. Donnelly Snipes. In this hour, ish, we are going to go through topics including ethical self assessment. We'll review the ethical principles and critical thinking guidelines, and then we'll go through what can be called a BS detection kit or and strategies to identify unethical behavior. Ethical codes empower us as professionals by clarifying our ethical responsibilities, identifying common methods for processing ethical issues, and helping us correct unethical behavior. Now, it's important to recognize the difference between laws and ethics. Laws are minimum standards. We have to uphold the law. Ethics are what they call aspirational. And we want to engage in conduct that most closely meets the ethical guidelines and obviously obeys the law. Unfortunately, with ethics, the majority of the time there is no super bright line, clear cut definition about this is okay and this is not okay. There are a few circumstances, for example, engaging in romantic relationships with clients, that's never okay. But other than a few instances, most of the time ethics requires a certain amount of personal judgment as well as consultation with other professionals. One of the guidelines that is used in lawsuits is did you follow behaviors? Did you behave in a way that another reasonable professional would have behaved? Which is why consultation is really important. So you're getting out of your own echo chamber. Ethics does not prevent you from getting sued, unfortunately, but it may prevent you from getting losing the lawsuit. People can obviously find lawsuits for a variety of reasons, but if you are behaving with integrity, if you are following the law and behaving ethically, then most of the time you're going to be very protected. As professionals, we need to adhere to ethics to maintain a practice. If the word gets out that we are unethical in our behaviors, that's not going to be good for us in acquiring new clients. Additionally, if the word gets out that we are unethical, we may end up with more litigation, we may end up with more problems that make it so we can't even stay open. And some ethical issues can get your license revoked. So it is important to recognize that the licensure boards based on ethical violations do have the ability to revoke your license. And even if it isn't a criminal charge necessarily, we need to adhere to ethics in order to protect clients. And there is such a diversity of clients out there, it helps us recognize what we can and can't treat. Are we trained to be able to treat XYZ diagnosis or XYZ population? And one of the things I talk about when I teach ethics at the university is I was trained when I went through graduate school, obviously I got a lot of training and you probably got a lot of training. And I got, when I went through, I got zero training on counseling children. Yes, I had a course in human development, but I got zero training on techniques like play therapy and sand tray therapy and those sorts of things. And so am I legally allowed to treat children? Yes. Am I ethically capable of treating children? And my answer is no. If for some reason I had to treat a child, if I was working at an agency and my supervisor said you need to see children, maybe you don't have the training yet, but you need to see children, then I would demand, I would require that, that I had supervision. So I would go back into weekly supervision with somebody who was trained and I would also request specialized training, continuing education type training in dealing with children prior to or early on in that change of job duties in order to ensure that I above all did no harm. Non malfeasance and adhering to ethics also enhances the profession. When we have a reputation as a profession, as people who help other people, people who are welcoming, people who are open minded and compassionate, that enhances the profession. And it's really helpful to have that high standard when we start talking about ethical thinking. Remember I said most of the time there are not any bright line rules. So we need to use our best judgment. And I can't emphasize enough how important it is to have other colleagues that you can consult with. It doesn't need to be necessarily official clinical supervision, but it is. When you're making an ethical decision, it is always a good idea to consult with at least one colleague, if not more. And you document that consultation in your notes, in your record so you can prove that. Yeah, you didn't just wing it, you were getting other people's input to make sure you were seeing the whole picture. Ordinary arguments are based on clinical conclusions. Does somebody meet XYZ criteria? In the DSM 5TR? We can make ordinary arguments because our agency says if a person meets these criteria, then they are or are not able to be admitted to this program. Okay. You know, those are pretty clear arguments. And ordinary arguments include a factual statement and a course of action. And if this, then that. Alright, that's great. However, these ordinary arguments are not always the most ethical. And what do I mean by that? Well, for example, clinical conclusions. If you've done a lot of diagnosis, you know that there are a variety of issues with differential diagnosis and for example, with personality disorders, when somebody gets diagnosed with a personality disorder, unfortunately they are stigmatized. And because of the way people in the general population, as well as a lot of clinicians, perceive personality disorders, instead of seeing it as a reaction, a behavioral reaction to help people survive a traumatic childhood, they see it as a problematic situation in the present and don't look at the communication behind the behavior. So your clinical conclusion, you're looking at it going, well, this person meets this criteria, have you effectively differentially diagnosed, and what should we, or ought we do in this situation? Maybe we should. If you think, all right, this person meets criteria, maybe it needs to be listed as a rule out instead of a hard line diagnosis. We used to do this a lot in substance abuse treatment because oftentimes people, when they would present in early recovery, would meet a lot of the criteria for, and meet diagnostic criteria for certain personality disorders. However, once they got a good handle on their recovery, in mid to late recovery, a lot of times many of those symptoms or behaviors were attenuated quite a bit or disappeared. So we need to think about what is the best thing for this client at this time that is legal and ethical, instead of just saying, well, the book says this, so this is what we do. Ethical principles, autonomy, beneficence, non malfeasance, fidelity and justice. And these ethical principles, I would hope, are true for every profession, not just behavioral health professionals, but for those of us in the behavioral health arena, whether you are a peer specialist or a psychiatrist and everything in between, it is imperative that we pay attention to these. Autonomy is empowering people that we see, whether you call them clients or patients or consumers or whatever word you happen to use, empowering those with whom we work to actively participate in their assessment, in their treatment planning, and in their own treatment. We don't want to overly paternalize people. We don't want to do things for them that they can do for themselves. For example, if they need to reach out and engage with some other services, depending on your client, they may be able to do it all by themselves. Thank you very much. If you just give them a name and phone number for other people, they may be so overwhelmed with, so intimidated that they need your assistance in doing that. 90% of the time when I've been working with clients, I've found that they've been able to do it on their own in my office, with support. They need someone sitting next to them saying, you got this, you know, let's do. Put the next foot in front of the other. And they're able to do it instead of me as their clinician doing all of the case management for them. We're empowering people to learn how to integrate with other agencies. For example, beneficence. This means doing something proactively in the best interest of the client. And that can be educating the public to destigmatize mental health. That can be advocating for somebody to help them access services. And we're going to talk about advocacy and some of these others as well. A lot of times things that we do don't adhere to just one ethical principle. There's a lot of stuff involved. But beneficence means proactively doing things to help clients and to, to prevent the development of mental health issues. So prevention is very much in the beneficence arena. Non malfeasance is the long word, the fancy word for above all, do no harm. And this one is the gold standard that we need to check in with ourselves every single day when we walk into the office. Non malfeasance. Am I mentally and physically able to provide effective services? Am I able to communicate and effectively work with the population that I serve without doing harm? And it's really important to regularly check in with ourselves because if we start getting burned out, if we're sick, if we're distracted, we may not be providing the highest quality of services. We are more likely to make mistakes. Fidelity means keeping your promises. If you say you're going to provide high quality treatment, then do it. If you say you're going to practice within the bounds of your competence, then do it. If you say that you are going to do something for a client, like set up a referral, then do it. Fidelity means adhering to your promises. Fidelity. Fidelity also means punctuality in my opinion. If we say, hey John, you've got an appointment at 3 o' clock today, then I am telling you that I will be available for you at three o'. Clock. I respect you and I will be true to my word to be available for you at 3:00'. Clock. Not, yeah, you get here at 3:00 clock and I'll see you, you know, by 3:30 or 4. That's not okay. And I think every one of us has probably sat in a doctor's office somewhere at some point for 30 minutes, an hour, maybe even two hours past our appointment time. And how do you feel and how does that reflect on the profession itself? A lot of people start grouping it together and saying, no, doctors respect my time. Instead of saying, this particular doctor was particularly disrespectful now you're not always going to run on time. What can you do? I had one provider at one point who was very good about having the administrative staff call upcoming appointments if they were running behind. OBGYNs will sometimes do that. If they end up having to deliver a baby, they may have their front desk staff call and say, you know, the doc is running about two hours behind. You can also call at the doctor's office before you go and ask if they're on time. And in terms of fidelity, the ethical thing would be for the front desk staff to say yes or no. And then justice means doing our best to ensure everybody gets adequate quality care. And I know those are a lot of extreme words, everybody, that's really difficult. And I think the majority of us in our heart and our gut really struggle with this because there's just not enough hours in the day and there are a lot of people who are uninsured or underinsured that that can't access services. So justice is another one of those, like beneficence, that involves a lot of proactive work. What can we do in order to ensure that people are getting treated fairly and accessing the services they need? Ethical self assessment. Do you live using a particular set of moral standards? I'm hoping you do. And there are a lot of people. To answer a question, there are a lot of people who are licensed professionals who have mental health diagnoses, something in this DSM 5TR. They have a mental health diagnosis as long as it is well controlled, then they are able and they're ethically able to provide services, then great. That's awesome. There is no prohibition, thank goodness, against people who have mental health issues from treating other people who have mental health issues. The ethical standard is to make sure that you've got your stuff in check so you're able to provide effective quality treatment that is ethical to people and you're not projecting your stuff or turning it into your own therapy session. Are you able to identify and explain your own moral standards? And that can be a little tricky because a lot of times we haven't had to articulate that ourself. But thinking back to those principles of autonomy, beneficence, non malfeasance, justice and fidelity, do you in general embrace those in what you do in life, not just at work, but in life, the way you treat other people, the way you interact with other businesses? Do you assess all ethical standards by the ethical situations by the same standards, or do you have different ethics for different situations that if this person meets this criteria, then I'm going to use these ethical standards. But if they meet this criteria then I'm going to use a different set or in this situation that's a personal thing that you need to be aware of. What affects how you apply ethics? Do you judge yourself by one set of standards and others by another set of standards? That's pretty self explanatory in terms of ethical decision making and ethical reflection. When you're trying to figure out how to solve an ethical dilemma, it's important to recognize that memories are often inaccurate and influenced by your expectations, your desires and and your emotion. And when situations happen that bring into question ethics generally, there is an emotional component that we need to acknowledge. Whether that is, should we enact involuntary treatment? Should we. How are we behaving towards this particular client? Are we feeling paternalistic? Are we wanting to nurture and caretake them when instead of promoting autonomy, what's going on? But we need to evaluate the situations from an awareness of what our own expectations, desires and emotions are. What's our own stuff and how is that coloring our interpretation. And that's why getting impressions from other people can also be helpful being because they are not going to be likely as emotional about it and they may have different expectations which can give us a different perspective, facts and impressions. Or your perceptions can be greatly divergent. So going back, one of the things that I think most of us have encountered in our history is whether or not we should enact involuntary treatment for somebody who is because they are a danger to themselves or others imminently. If for example, someone has already been through this situation and they had a negative outcome, then when it occurs in the future, they may be more likely to feel that it's more urgent than it really is and proceed towards involuntary treatment quicker than maybe is necessary. Likewise, if somebody's been down this road multiple times and they've chosen not to enact treatment, or they've sent people to crisis stabilization and the psychiatrist said no, you know, we're not going to admit for involuntary treatment, then they may be less willing to go through that process again. They may take a more lackadaisical attitude, which can also be very dangerous because they are potentially not taking things as seriously as they need to. So your impressions and your perceptions often are based on your prior experiences and may not completely jive with the facts. When making ethical decisions, try to get a clear picture of what's going on by examining multiple perspectives. What is the client's perspective? What is your perspective? Ideally, get another professional's perspective and maybe one other in there. If you're working with somebody, what is their significant other's perspective? Try to figure out how other people see the situation and what you think that they would do or they would want done. Provide objective, relevant reasons whenever you give a diagnosis. One of the things that used to really irritate me when I was a supervisor is I would do chart audits and I would see this assessment and all the blocks were filled in, but then there was this diagnosis. However, nowhere in the assessment or in the clinical formulation at the end did they actually articulate how the person actually met the diagnostic criteria that they need to meet for depression or anxiety or whatever the diagnosis was. And it's important if we're going to give a diagnosis that we are able to articulate, the person meets this criteria, as evidenced by. The person meets this criteria, as evidenced by. In order to support treatment. That way we can identify, okay, they have this symptom, this is the behavior. So. And it makes it a lot easier to identify treatment targets. We need to use reliable and verifiable data, which means information that comes from the person, not necessarily secondhand. Now, it is helpful a lot of times to get information from other sources if we're able to. In terms of medications, this is the one that came up for me a lot when I would do assessments. People wouldn't bring their medications in and were getting ready to. We're going through this assessment for intensive outpatient treatment or whatever, and I'm guessing, you know, they're trying to remember the name of a medication or the dosage that they're on. This was especially problematic when they were admitting to detox and so they were under the influence. We need to use reliable, verifiable data when at all possible. So if the person gives mental recall data about something like medication, for example, then we want to get verification of that data as soon as possible. Get a release sign so you can contact the physician, have them bring in their medication bottles, what, whatever protocol that you use. We need to provide evidence for the selected treatment approach. Now, in other ethics classes, I've talked about empowering the client and being culturally sensitive. And when we do that, we ask people, what is it that you think is contributing to your current situation, your current presenting symptoms, and what is it that you think might help? Some people from different cultures may embrace different approaches. Some people will want to use spiritual leaders. Some people may want to use more Eastern medicine approaches that we may not be as familiar with. And it's important that we balance evidence based with consumer choice and autonomy when we select a treatment approach. If we say, I think this might be useful for you, this approach might be helpful. Based on these criteria, we need to know that we're selecting an evidence based practice, which means there's been some research on it that identifies that it can be helpful. We need to cite information regarding how we arrived at our interpretations of things, as evidenced by that phrase should be your best friend in documentation. Allow for some wiggle room in your interpretations. If you say something subjective like the client appears to be having a bad day, appears gives you some wiggle room. I tend to shy away a fair amount from subjectivity in a lot of my documentation and opt instead for objective assessments. But if I say Sally appears to be having a bad day, as evidenced by, then it gives me the ability to say this is what I'm seeing and this is how I interpret it. However, I haven't asked Sally how she feels yet. Take into account the limitations of any treatment modality selected. So important. There is no one size fits all treatment. There is no one treatment that works for everybody for a particular diagnosis. There are treatments that seem to work better for a lot of people, but we can't say if you've got ptsd, then EMDR is going to work for you. We can't say that it works for a lot of people, but not for everybody. So we do need to recognize limitations. We need to recognize who it's appropriate for. For example, somebody who's in a actively psychotic episode probably is not going to benefit very much from cognitive behavioral therapy or reality therapy. So we need to recognize that we need to embrace people as individuals in the moment. How are they presenting today? If you have somebody who has bipolar disorder, for example, and they present one day and they are in a depressive episode, your approach may be somewhat different than the days that they they present and they are in a manic or hypomanic episode. Recognizing what treatment strategies work best at any particular time. When you make an argument, and argument is something we talk about in proofs and math and those sorts of things. I'm not saying we want to argue with things. When you make a good premise, your idea, premise or argument, if you want to use that word, must be true. The reasons for your argument must be relevant and adequately supported. For example, if you say abstinence is a necessary goal in early recovery for all people with addictive disorders, can you identify all of the relevant reasons why abstinence is necessary and the relevance and validity of the Supporting data. And why did I choose that one? And those words specifically? Because there are certain addictive behaviors, while not identified in the dsm, certain addictive behaviors that you may not be able to completely abstain from or not wanting to completely abstain from for an extended period of time. And so it's important to recognize that in terms of chemical substance abuse, abstinence has been shown to be extraordinarily helpful early recovery to allow the body to recover. So we need to weigh ethically for if somebody is identifying as a sex addict, for example, and we say, well, you need to abstain from sex for the next six months, how is that going to impact them? And I'm not saying that that's a treatment goal, I'm just giving a hypothetical. How is that going to affect them? Yes, it may help their dopamine system get a break, possibly, but how is it going to affect every area of their life? And is that a goal that they want to work towards? And what are the alternatives? So let's talk about the BS detection kit. When you go to a conference or when you're taking a CEU class or reading a book that has been written by somebody, are the ideas and principles you're hearing clear or is the reasoning circular in nature? Is the person able to articulate if this happens? If a person presents with major depressive disorder, this treatment has been shown to improve symptoms, or are they saying something like inflammation contributes to depression and depression treatment will reduce inflammation without giving you any evidence why, you know, support that. If you're going to have a something that interacts reciprocally with, with one another, can you defend it? What is the reasoning or the chicken egg reasoning that you can use to identify why addressing inflammation might help depression or vice versa? Why addressing depression might help inflammation? You need to have the evidence. Are your ethical decisions supported with relevant, valid and unbiased evidence valid? Is it measuring what it purports to measure? If you are saying this treatment, we'll say cognitive behavioral therapy because most people are familiar with it. Cognitive behavioral therapy is, is appropriate for a particular population. Is the research based on, has it been tested on that particular population? Cognitive behavioral therapy with a five year old probably not going to be very effective because cognitively they are not as able to think in the same way. So the information, the data you're using must be relevant to the person or the people that you're working with. It has to be valid. You know, what was the quality of the research that was done? And it's easy, relatively easy. To go in PubMed and look at some of these things and is it unbiased? Look at the researchers. And at the end of Every article in PubMed there is a conflict of interest statement. At the end of every article that's in a peer reviewed journal there's a conflict of interest statement. But if somebody is providing information and a lot of websites do this, if you go to a particular doctor's website, they may present you with biased evidence that only supports their point of view. Are there any qualifications that may need to be made with a particular ethical claim, such as in this instance when working with this population or due to the circumstances of this case? These were the interventions we chose and this is what happened. We can think about ethical decisions when it comes to, for example, calling the abuse hotline, who makes that call. And this goes back to autonomy. A lot of times when I work with clients, if it is ethically appropriate, then I will encourage them to make the call while they're in my office so I can document that it happened. I will empower them to do that. It's a lot more effective. In terms of the therapeutic relationship. That's not always the most ethical decision. If it's going to put somebody in jeopardy, then you may not want to do that. And that's. I go over that a lot in the class on abuse and neglect indicators. Breaching confidentiality to let a parent know that their child is having suicidal ideation. Now a lot of states will have some regulations about that, but I want you to really focus on suicidal ideation. Where on the continuum is that person? Did the adolescent come in and just spout off something that indicated some mild transient suicidal thoughts or are they actually intensely considering it? There's, there's a difference there about whether it would be the most ethical decision when you breach confidentiality. When you involuntarily commit somebody to treatment, it violates and disrupts the therapeutic alliance, the therapeutic relationship. So you need to weigh that and say, does this rise to the level? That is something that I have to do. I have to remove the person's autonomy in order to keep them safe. Warning a significant other of a person who has HIV that the person is infected. There are a lot of rules about this and it's important to note that the rules about warning identifiable others who are in relationships with somebody who is HIV positive or has AIDS vary by location. What you're allowed to do and what you're not allowed to do by law. You need to know what the laws are and the regulations are regarding privacy, confidentiality, and anything to do with communicable diseases in your particular area. Is the presenter staying on point and following a logical sequence? If you go to a conference or you're reading a book or whatever, and it seems like it's all over the place, it could be that that person's just a bad presenter, it's possible. Or it could be that they are trying to jump around and keep you distracted so you don't actually follow some logical rationale. Are they using objective, unbiased support for the claims made? If you are, and I've been to a lot of conferences where people present and they are, their treatment center specializes in XYZ treatment, that's great. But if the only data that they're presenting is data that comes from research that they've done with their people on their clients, that's not necessarily unbiased support, because there's a lot of ways of interpreting data, as we all know, it's best to. If they're also citing other studies in the uk, they've done this, or at this other clinic, at the Mayo Clinic, or wherever research is indicated. So if there are other unattached resources or sources of supporting information, that adds a lot of credibility. Are you able to paraphrase the claims? Paraphrase the claims or points? If they're jumping all over the place and they're not making a connection between two points, or they're not actually presenting something that you can walk out and go, okay, I learned this in this conference. That may mean that they are either trying to intentionally keep you off balance so you just believe what they say, or again, it may mean they're just a bad presenter. Are alternate conclusions considered and given any weight? For example, EMDR is the best treatment for all types of trauma. One might say that, but what is the evidence? And I always encourage my kids in their decision making, my supervisees in their decision making, myself. If I believe that this is the best treatment or if I believe that this is the best thing, I argue the opposite point. What other options are out there and why would this not be the best? In order to broaden my awareness, to get out of my own echo chamber. Is the argument information complete? Did the person identify the pros and cons? Humanistic therapy or cognitive behavioral therapy? Neither one is perfect for every single individual. So what are the pros and cons of each approach? And. And many times it's helpful to present that to clients when they're trying to decide, you know, what treatment to engage in. For example, or even treatment levels, outpatient versus IOP versus residential. All three levels have benefits and drawbacks, however, and it's important that we let clients know what the benefits and drawbacks are so they can make an informed choice. Ideally, at the end of any presentation, there will be points of summary and closure. So the person says, okay, this is what we talked about today. If they can't even paraphrase their own self, then there's probably a problem in terms of evaluating conclusions. If I say this, this is the best treatment for that. It's important to observe and identify when you are engaging patients with X diagnosis with this treatment. How effective has it been? Form a hypothesis test, experiment and rule out alternative explanations. I fuss about this a lot on my channel. The differential diagnosis is so important. For example, people with major depression who meet the criteria for major depressive disorder, assuming it is all because of cognitions or even behaviors, is foolhardy. We need to rule out alternative explanations like like hypothyroid and anemia and vitamin D deficiency and several other physiological issues that may produce symptoms that mimic major depressive disorder. Until those things are treated, the person is going to have a ceiling on how much better they can get. There's only so much that talk therapy can do. And then refine and retest your explanation. Can you support it with relevant, valid evidence? Over 20 years, when I have worked with patients who presented, for example, with a mood disorder, I have found that not all the time, but it's not infrequent for them to have some underlying comorbid physical health conditions that are contributing to to their mood and energy and pain levels. So my experience has supported that. The research supports that hypothyroid, for example, and polycystic ovarian syndrome may produce symptoms of major depressive disorder. It doesn't mean that there's not some cognitive stuff going on there too. But my hypothesis has proven right many times in the 20 years. Like I said, not everybody has an underlying physiological issue. Sometimes that's not it. Not everybody has an underlying history of trauma. So that may not be it. But it's important to be aware that everybody's an individual and be able to support your decisions with relevant, valid evidence. Another model for ethical decision making. Identify the problem, apply your ethical principles, and I encourage people to go through each one of them is whatever I'm wanting to do or needing to do. How can I best support autonomy? How can I make sure I do no harm? Is there anything that I could do that would be beneficent or proactive for the client and am I being faithful in what I've told the person I'm going to do and am I making sure that they have equal access? Am I making sure that the justice principle is involved? Consult with a colleague. Generate a potential course of action. Consider the pros and cons of all options. If you do this, these are the potential outcomes. Let's take treatment placement. If the person goes to regular once a week outpatient, these are the pros and cons. If they go to intensive outpatient, pros and cons, residential pros and cons. And then helping them make a decision making based on those pros and cons. Evaluate the selected courses of action for ethicalness and legality. Obviously, if somebody meets criteria for level four residential treatment and you recommend once a week outpatient, that may not be the most ethical recommendation. And it's important to to evaluate that it doesn't. Your recommendations don't necessarily mean what the person is going to do. It means your recommendation and then they have the option. If you recommend intensive outpatient and they're like no, I'll do once a week, okay, that's their choice. You're enabling autonomy. But it is important that you make the ethical recommendations. You implement the choice and evaluate the outcomes. How do you know if you're being ethical? Have you been honest professionally and personally? Ask yourself, are you acting in the best interest of the client and or obeying all applicable laws? Sometimes it can be. Well, not sometimes. It's always difficult to make a call to the abuse hotline. It's always a difficult decision to make a decision. Make the call to enact involuntary commitment procedures. However, there are certain laws, mandatory reporting laws and Tarasoff that laws about protecting people from imminent harm. So you need to obey all applicable laws. Even if you don't like it, you need to make sure that you are obeying it to the best of your ability. Are you acting without malice or personal gain? And most clinicians act without malice. I haven't seen a whole lot of malice coming out. Personal gain bothers me because I have seen clinicians keeping people on caseloads for way longer than they needed to be, which goes against that whole autonomy and fidelity and even non malfeasance because the person is a good client. They show up every week, they show up on time, they pay their bills, but they reach maximal levels of improvement and the therapist doesn't discharge them. Instead they stay on the caseload for years. And it's really important to regularly evaluate everybody on your caseload. And say, do they still need to be coming to treatment this frequently? Can you justify your actions based on the state of the profession? Would you be embarrassed if somebody found out? If a colleague found out or your grandmother found out or your best friend found out, Would you be embarrassed? Would you be ashamed of what you did? Do you feel like it's something you've got to sneak around and do kind of under the COVID of darkness? If so, it's probably not ethical. Finally, if tables were turned and you were the client and somebody did this to you, would you be angry? If so, it could be unethical. Ultimately, I say ethics before earnings, and I know we've all got to put food on the table, but there are so many clients out there, there are so many people needing services, and that even if we have to turn away some people because they have, they're presenting with an issue that we are not adequately trained to treat, or because they don't have the insurance that we accept, or because they've met maximal gains at this level of care and we need to at least temporarily discharge them. That's important right now. Especially, I don't know any therapists who are seeing clients who are twiddling their thumbs going, I can't seem to fill my caseload. Pretty much as soon as they open an appointment slot, it gets filled. So ethics before earnings. But that also means not burning yourself out. I personally and every person's threshold is a little bit different. I personally won't see more than four patients in one day. Seeing patients requires a lot of cognitive and emotional energy. And for me to give them everything that I feel they deserve and provide the highest quality of treatment. Four therapy sessions a day is my max. Now I can do assessments in the other hours that doesn't require the same level of intensity. And. But for me, that's where I draw my lines. And I recognize that I'm just. My earnings may be capped out because of that, but that's okay. I'm behaving ethically. Always evaluate your data. If you and a client agree that, hey, this is the diagnosis, this is the treatment we're going to use, and then you start using it and. But you never go back and look to see, is this person making progress, that's unethical. If you are basing decisions on treatment, what kind of treatment to use for a particular person or situation, evaluate the data for the validity, the reliability, and the appropriateness for that individual at that time. Consult. I strongly encourage every clinician to have a network of people professionals with whom you can call up and just bounce ideas off of. You don't have to violate confidentiality. You say I have this client and my client is almost always Jim Bob. I have this client Jim Bob and this is what's going on. What is your take on this situation? So you don't need to worry about violating confidentiality. Now in certain circumstances if some of the facts in the case would make the person easily identifiable then you need to remember that you need a signed release of information and then document, document, document, document, document what you do with people. Document how you arrived at your conclusions. Document when you consult because if it's not written down it didn't happen. And if you ever are in a position where you have to appear at a sentinel event review after something bad happens, you need to be able to show this is what we did not say. Well I think this is what we did show it. It needs to be documented.