Ethics Nonmalfeasance | Counselor Toolbox Episode 87

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allce.com counselortoolbox you welcome to today's presentation on ethics, beneficence, and non malfeasance. I know this sounds like a really, really exciting topic, but actually it kind of is because I find there are a lot of times that clinicians inadvertently commit some ethical violations or there are things we actually could very easily, easily do under the guise of beneficence that we don't do. So there are things we could actually do to become more ethical, if you will. Since ethics is actually an ideal that we strive for, obeying the laws obviously is our minimal competency that we have to uphold. But ethics holds us to a higher standard. What could we possibly do? What would it look like if we were the most ethical, best clinician? So we're going to define beneficence and non malfeasance and explore the violations of this practice in addition to things we could do in order to become more beneficent. So beneficence is the more fun one to talk about because it's proactive and it's positive. It's a proactive action that's done for the benefit of others. Beneficent actions can be taken to prevent or remove harms and improve the situation of others. So sometimes in order to be beneficent, we may want to look at ways we can volunteer. We may try to write grants for our organizations that can get funded by SAMHSA or something in order to remove some deficits or issues in local school systems or in local communities. Along with removing the harms, we're automatically sort of improving the situation of others. The goal of counseling is to promote the welfare of patients. We're not hopefully always going to be reactive. We want to be proactive. If they come to our clinic and they are dealing with depression, okay, so they're dealing with depression. But let's deal with depression before it becomes depression and alcohol addiction and generalized anxiety disorder and kind of gets spirals. Or let's deal with it while it's depression and it's not negatively impacting like every area of the person's life and help them deal with it then, as opposed to waiting until they're clinically depressed, they've lost their job, their relationship with their significant other is on the rocks, etc. Due to the nature of the relationship between clinicians and patients, we have the obligation to prevent and remove harms, which means we need to identify what's harmful. And one of the things that I experienced a lot when I would go through JACO and CARF accreditation procedures was looking at some things that are inherent in some of our larger organizations and trying to identify of these things that are that we do on a day to day basis, which things are we doing that may inadvertently be harmful. So looking at it from a multicultural perspective, looking at it from a trauma informed perspective, and we also want to weigh and balance possible benefits against possible risks of an action. When we're dealing with people with co occurring issues, we may refer them out to self help groups, we may refer them out to 12 step programs or celebrate recovery or smart recovery. We want to weigh and balance possible benefits of referring them out to self help programs as opposed to counseling versus in addition to counseling we also may want to look at if you have somebody with a true co occurring disorder and you refer them to a sort of an old timers if you will, 12 step meeting, that person who may be on psychotropic medication may not be received as well. So we want to balance the need for support for addiction recovery with is this person going to be accepted given their current treatment protocol? Beneficence can also include protecting and defending the rights of others or advocacy. So we want to ensure the use of culturally sensitive trauma informed approaches. We want everybody who walks into our our lobbies to feel comfortable, to feel confident, to not be re traumatized especially we want to be as open and welcoming as possible. We want to ensure the availability of effective referral sources to meet the needs and preferences of clients for whom we may not be a good fit. You know, there are times I've worked with clinicians who have no training working with addictions or very little training in working with addictions. So they have wanted to refer clients to me and that's great. And there have been times that I've had clients who've had certain issues that I haven't felt as equipped to deal with. So I've wanted to refer out or they've needed or wanted to use an approach like EMDR that I'm not trained in. So I need to be aware of the resources and referrals in my community. Not only you know who they are, but are they effective. I want to know that if I'm referring a client out somewhere that I am making a referral to someone who's competent. State licensure obviously a good indication that they have a minimal competency. But we also want to make sure that it's a good fit for. For the client. If your client responds best to a CBT approach, making sure that we're referring out to someone who is comfortable with CBT or DBT or family systems or whatever it is, we want to make sure that we're not just sending somebody out going, well, this is another licensed clinician, you know, go see what they can do for you. We also want to make sure that this person is, and I'm trying to choose my words carefully, we want to make sure that they're good at what they do. And there are some clinicians that I've worked with and that I've known of about who have had some issues with either not being. Either working outside of their bounds of competency or not being able to perform the job because of some personal issues they had going on. So, you know, I always want to be alert to what's going on when I refer my clients out. If I'm referring them out for what I want to call supplementary counseling. If I'm going to still keep working with the client, but they want to go through some EMDR treatment, then we may still coordinate on a multidisciplinary team. But I also want to hear back from my client, how are things going? How is that fitting for you? And it may not be because the clinician is not a good clinician. It may not be an effective referral for that particular client. So then as the coordinating clinician, I need to say, okay, what's not fitting well? And let me see if I can help you find a couple other resources ethically. I was always taught that when you make referrals, you should always give three referrals. So I try to keep a spectrum of people to whom I refer available, and that way I can tell the person, well, this person uses a dialectical approach, this person uses a humanistic approach, and this is what that means, and etc. So we can talk about the different things. And I'm not necessarily saying this would be where I would go. I'm saying these are your options. Let me help you make an educated choice about where you're going to go, and then the person can choose from there. We want to ensure that we do timely advocacy for our clients with the insurance company for additional session authorization. I really hate when a client shows up and, you know, maybe they were authorized for 10 sessions and the clinician didn't authorize additional sessions, and this is their 11th. So now the clinician's going, well, we didn't get you reauthorized. Why don't you sit there and I'll see if I can get an emergency authorization. That's not good for the client, that's not good for the business, but you know, you can't guarantee that additional session authorization either. We want to make sure that we advocate for the client. When we call to see if the insurance company says no, we authorized eight sessions and that's it. Then doing whatever we need to do to appeal the process ahead of time to make sure that there's no break in treatment for that particular client. Another thing that we can do as clinicians, especially if you work at an agency, it may be a little bit more difficult in private practice, is to make sure you have a, what I call a drop back and punt plan. If the insurance company refuses to authorize any additional sessions and the client can't afford your normal hourly rate, are there other options? Are there other referral sources you can send them to? And. Or I usually have three groups going that I can refer people to who either A prefer group treatment or B don't want the cost associated with, associated with individual treatment. So they can still have continued treatment until we can either get more sessions authorized or you know, whatever the case may be, we can have a successful resolution of treatment. We also want to advocate, and I've done this a lot, this came up for me a lot. Working in co occurring treatment, advocating for the patient with the treating physician, which also means being an effective member of a multidisciplinary team. If you're working within the same organization, sometimes it's easier because you're sharing the same case file and you can put a note in the case file for the physician. If you're working in private practice, but the person is also seeing a psychiatrist or physician to get their medications, it's important to try to get those releases of information signed so you can help advocate for the client as needed. I mean, sometimes the physician is spot on and there's very little you need to do. But effective communication between treatment members is always in the best interest of the client. So you can understand, you know, what the doctor thinks about the client's current progress and what prescriptions they're on, etc. In CO occurring treatment, one of the things that we often find is there are some docs that are still of the mindset that somebody needs to have six months of clean time in an uncontrolled environment. So not in residential treatment, not in jail, but in an uncontrolled environment. They need to Be clean before the doctor will prescribe any psychotropic medications. And this is like your basic antidepressants. We're not talking Ativan or something that has high abuse potential. And you know, as over the past 20 years, as we've learned that co occurring disorders are the expectation, not the exception, we've also learned that people in early recovery, they stop using their neurotransmitters are out of balance. Their depression and their anxiety and you know, all that stuff hits them like a ton of bricks. Expecting them to stay clean and sober for six months without, you know, being able to feel happiness without, and with this oppressive depression, it is pretty unlikely. So there is a percentage, and I'm not saying every patient, but there is a percentage of patients who really want and need to be on some sort of antidepressant during that early with early recovery period. So advocating with the physician for the patient is sometimes necessary. I've also had other times where patients have been, they've had this sort of white coat thing going on where the doctor will tell them exactly how they feel and what they need. And it's this in and out, 10 minute thing. And the patient talks to me and says I'm feeling this way and the medications aren't working and yada, yada, yada, they go to the doctor and they don't open their mouth and they come back the next week and I'm like, well what did the doctor say when you told them that the medications weren't working and all your side effects? And they're like, yeah, I didn't bother to bring it up. So you know, obviously that's a clinical issue that we can work on in treatment for self advocacy. But in some cases it's helpful to advocate with the physician by sending over a case summary of what's going on and what the patient reports. You know, I'm not second guessing the doctor. You know, there could be other things going on, but it is important in my mind as part of a team to make sure that the doctor knows what the patient's telling me. So I may get those signed release of information, fax over the current status of the client and what is being reported to me with regard to the medication, hopefully before the client goes and sees the doctor and then, you know, the doctor can choose what to do with that. But it's important to make sure that you're make yourself available. So clients who feel intimidated by their physicians, not because the physician is necessarily intimidating, but just because the physician's a physician that we can be there to help them and help them learn how to self advocate. I told you beneficence was a lot more fun than non malfeasance. Beneficence can also include helping individuals struggling with mental health or addictive disorders find effective treatment based on their readiness for change. Now that's kind of a two parter there, finding effective treatment and actually I probably should have done this ahead of time. Let me see if I can make this go away. SAMHSA has a really good website that can help you find treatment really quick for clients. And I'm just going to move this down into our window and. SAMHSA treatment locator. I go there a lot so it's already purple. Enter a starting location. I looked for something for somebody the other day who was in Florida. So you type in your basic starting location and then up here you can start narrowing it. So I put in the city name. I want to narrow it to only the things that are within that county, which happens to be Broward County. Well that's still a lot of stuff. So how do I narrow it down to meet my clients needs? Well, I can do this dropdown and I can look for the type of therapy offered, inpatient, residential, outpatient, different payment options, whether the organization has someone who can accommodate a Spanish speaker, special populations that may need to be addressed, and age groups. So you can really narrow it down based on what your client's needs are. Now this isn't every treatment center in that area. These are only people who have registered with samhsa. So I'm not saying this is the only way to find it, but if you need to somewhere to start, this is a good place to start because most of your larger agencies have registered with SAMHSA so you can find them. And most of your agencies that have state funding and federal funding are also on here. So if that happens to be a criteria that's important for your client, then you know you got that. So that's finding effective treatment. And of course going back to that term effective. By being active in your professional associations and in your local clinician clinical community, you'll get an idea about what services are offered and how clients feel when they go through certain treatment programs. If they feel like they were a number, if they feel like they were really cared about, if they feel like they were helped, obviously this is going to be different for each client. Some clients are just not going to be happy anywhere. Other clients are much more passive. But it's gives you a general go by. I also Encourage everybody to go out and meet other clinicians, go to their treatment centers, get a tour, see what they have to offer. Especially treatment centers that have multiple programs. Go in and explore. What does it feel like to you? Does it feel oppressive and intimidating? Or does it feel very welcoming and like it would be a place where you could really, really talk about your stuff? Then there's the readiness for change. And this is something that we talk about more in addictions treatment than mental health. But both are true, or both have a level of readiness for change. Pre contemplation says I don't have a problem. You can't tell me I have a problem. You may have a client who shows up in your facility in pre contemplation because a judge or an attorney or, or somebody told them they had to be there, an employer. So putting them in a residential program probably not going to be the best fit because they don't think they have a problem. So are they going to benefit from that level of care? Most likely not. We also want to look at. Then you have people who start going, well, maybe I've got a problem. They're ready to start dipping their toe into it, but they're not ready to start making huge life changes like IOP, which is 15 hours a week, or residential, which is, you know, 24 7. So we want to look for something that's either a low intensity IOP or an outpatient program. We, we may want to look for groups as opposed to individual therapy. So talking with your clients about what are they willing to work on, what are they ready to change and what do they see as being the ideal treatment environment for them. We also want to increase awareness of the problems of co occurring disorders in their treatment. You can go to the NIH.gov or SAMHSA.gov and SAMHSA.gov and order patient handouts for free. They're beautiful printed, glossy color handouts that you can have in your waiting room to educate clients. It's not something that you as a clinician have to come up with and pay to print and all that kind of stuff. It's free, they ship it for free. So having these available, I usually order extra and hand them out to local physicians, school resource officers and school counselors so they can disseminate the information a little bit more to help people become more aware of issues such as ptsd, generalized anxiety, postpartum depression, and of course addiction and behavioral addictions. Because we're starting to really talk about those now. What is Internet addiction, what is gaming addiction? What is sex addiction? And how does that differ from just normal playing on the Internet or sexual relations? Increasing awareness of when things become a problem can help people get early intervention. And guess what early intervention means? It's going to be a whole lot easier to treat than if you wait until the person's life is crumbling around them. Getting continuing education. That's us getting continuing education to ensure awareness of current best practices for treatment. One glaring example, if you will, the protocol for handling trauma for critical incident stress debriefing has changed over the years from the need to shift for the need of each person to share their detailed account of what happened in session to more of a supportive environment. They've realized that these detailed accounts of everybody sharing in the same room often causes secondary trauma and a whole lot of other stuff. So being aware of what the best practice is for whatever you're treating, if there are, I know right now there's a new best practice or a new treatment guideline out at SAMHSA for treating people who are glbtq. So you can go again onto the SAMHSA website. Let me pull that one up for you, because I love that website. I always like things that are free though samhsa. So you go over here to their series and their tip series, not the quick guide, Treatment Improvement Protocols. These are your books, and they're generally like, you know, couple hundred pages that will train you in things from detoxification to group therapy to GLBTQ issues. Let me see if I can find that one. Okay. This isn't the one I was thinking about, but this is a practitioner's resource guide to helping families support their LGBT children. So there's a lot of stuff, and obviously it's a PDF. You can print it out and you can order the real pretty glossy printed copy for free from samhsa. Okay. So continued education and being aware of current best practices, providing patient educational videos or handouts in the waiting room or on your website to help them take charge of your health, of their health. Some of these that I'm showing you on soms that you can link to them from your website, or you can download the PDF and have it available on your website. SAMHSA is really nice about copyright. They're just like, you can use this freely. We want to disseminate the information. Your tax dollars already paid for it, so you can make that available to people. There are Spanish versions that are available if your clients happen to be native Spanish speakers. So that's another bonus. Working with SAMHSA or nih, you can get handouts that are already translated for you. Another thing we can do is ensure a signed release and provision of necessary information to referral sources before the patient arrives. Please do. If you're going to make a referral, that's great. But also get a signed release of information and follow up getting that information to the referral source before the patient gets there. Because if you're faxing it after the patient gets there or that same day, a lot of times the clinician won't be able to get to it, to read it, to be prepared to see the client. So that's a real simple one. Oops. On to non malfeasance. Do no harm. Refrain from providing ineffective treatments. Even if something is an effective treatment that some when somebody else provides it, maybe it's not your thing, maybe it's something that you don't feel like you ever quite hit the mark. So get more training on it before you start providing it to clients. Avoid acting with malice towards patients. Some people will have different opinions about what kind of treatment is going to be best for them. I've seen this a lot in co occurring facilities that were 12 step focused and if a client comes in and says I don't do 12 steps, there was often an attitude of disdain and well, you're not serious about your recovery if you don't do 12 steps. So again, back to the advocacy. Educating the clinicians that are that there are other support groups out there and ensuring that the people in your treatment facility are respectful of clients, treatment wishes, etc. Assist patients in making best treatment decision for them, not one that provides us the most benefit. If a client needs treatment for co occurring disorders Treatment for addiction because often addiction is the one that has the widest range of services. They come in, they say, you know, I'm alcohol dependent. We get them through detox and you go through the treatment protocols, placement criteria, identify this person would benefit from outpatient treatment. However, you have an IOP program that has three slots open right now. So do you try to talk them into IOP saying well, it couldn't hurt or do you encourage them to to evaluate the treatment options and find the best fit for them? Because IOP has its own drawbacks like having to rearrange their schedule, being more expensive, etc. With all interventions, ensure the benefits outweigh the risks. Remembering that there are certain things that may be traumatic to people. We had a program at one of the facilities I worked for. We had acupuncturists come in twice A week to work with anybody in the program who wanted to participate in acupuncture. Well, that's great until you start thinking about the fact that a lot of the people that were in our program were abusing drugs with needles. So when they are put in a situation where they are in acupuncture situation, some of those clients felt very triggered by the presence of the needles. So we switched them over to magnets. It was an easy adjustment for that particular clinician to do because she was educated in how to work with people in our particular setting, but making sure the benefits outweigh the risks. We know that acupuncture has been proven to be helpful with cravings and recovery from addictions, but at what cost? Ensure the patient is provided with all treatment options and can choose the least restrictive treatment environment. Enough said on that one. Don't provide a treatment that has not been shown to be effective. So maybe you went to school with somebody who came up with this really awesome treatment and you know, it's not derivation of something that is currently mainstream. I mean, we've seen CBT kind of become DBT and act and they're all very cognitive behavioral in nature. But if this friend of yours, a colleague of yours that you went to school with, comes up with this treatment that is completely new, not tested, it's really unethical to just start saying, well, let's try it on some patients and see what happens. There are a lot of institutional review board ethical protocols you have to go through if you're going to use an unknown treatment on clients. So, you know, it's just better to avoid those. Try not to make blind referrals because you can refer potentially to someone who would do more harm than good. If you're making a referral to just some random clinician in your city or in the next city over and you have no idea what their approach is or what their feelings are about particular things. Maybe you're referring a client who is dealing with some PTSD issues and this particular clinician doesn't believe that PTSD really exists, then you might be causing more harm. So make sure when you're making the referral it's an appropriate one. If you're making a referral to somebody who is not state licensed, because state licensure we assume, and I use that term kind of cautiously, people who are state licensed or certified have met certain minimal qualifications. So educationally we can be pretty confident that they have the minimal qualifications. But then there are other people to whom we may make referrals that aren't required to be state licensed or certified. So it's important to know to whom you are referring. In Tennessee there are certain, and I don't remember what they're called right now, they change the terminology. It's a semantics thing. Let me go with Florida because I know that one better. There didn't used to be regulations on sober homes in Florida. So when people would get out of treatment, they would go to these places called sober homes that they were supposed to be able to continue their recovery process in a safer environment than the dysfunctional one out of which they came. Well, that didn't turn out to work so well because a lot of sober homes were not any less dysfunctional. So the state of Florida has started regulating sober homes. But we want to make sure that, you know, wherever we're sending someone, even if we're giving them three choices, we want to make sure that all three of those choices are going to be places that could benefit them in one way or another. Don't encourage clients to collude in insurance fraud, diagnosing them with a disorder they don't have in order to get reimbursed. If you have a client who comes in and they're presenting with just general problems, but they don't meet the threshold for anything. I mean, not even adjustment disorder. Or maybe they meet the criteria for adjustment disorder but their insurance doesn't pay for it. So you go, okay, well you most closely meet the criteria for major depressive disorder, so we'll go with that. So your insurance company will pay. That's not okay. Yes, they need the treatment. However, if you're diagnosing them with a disorder they don't have, there can be other repercussions. A their insurance premiums could theoretically go up. That used to be under the old system. I don't know how it is anymore. And you know, if somebody else comes out and says no, they don't have this, then there could be issues with you being able to continue to provide services to people under that insurance company. Don't change diagnoses when benefits for one run out. I see this a lot in co occurring disorders. Somebody will enter treatment and they will expend all of their substance abuse benefits. So then all of a sudden their mental health issues become their primary diagnosis. Now you can argue both sides because co occurring philosophy says both disorders are primary. However, you know, it's really kind of a sticky path that you're walking if you start switching diagnoses. Please discharge clients when they've met Maximal gains at that level of care. Too often clinicians will keep clients on their role because the client enjoys coming and they enjoy seeing that client. It's a dependable client. You know they're there, that you get paid every week and you don't have to fill that slot. There's a certain point at which we're starting to create either a dual relationship where it's more of a friendship than a therapeutic relationship, or we're creating a dependency, saying, you need to keep coming because when life throws you a curveball, you're not going to be able to handle it. So I need to be here for you. Don't bill for services under a therapist that were provided by an intern. This is another one of my big pet peeves. Most private insurers and Medicaid and Medicare explicitly say if the service is not provided by the clinician, you cannot bill for it. This is especially true if you have maybe somebody running a group and a licensed clinician is billing for running the group, but they had an intern run the group and the licensed clinician wasn't even in the room. Major bad mojo. In most cases, this is against contractual obligations and you can lose your contract with that insurance company as well as, you know, potentially face fraud charges. But avoid, when possible, referring a patient back to the same treatment program they've already been in multiple times and relapsed. Sometimes you go through one time and you don't get everything, and you go through a second time and you get more, but you still don't get everything you go through a third time. You should be pretty close to getting everything you can possibly get from that treatment program. When we're dealing with people with addictions, a lot of times we see people, people come through the same program five, six, seven, eight times. And my thought is, well, if what we provided for you the first four times didn't work, what are you hoping or expecting is going to be different now that will help you stay clean longer? Because clearly something needs to change. What we're doing right now isn't working, and we're just redefining insanity, continuing to do the same thing, expecting different results. Sometimes it's not possible. Sometimes it's the only treatment program that's available to that person based on their insurance and everything else. So some treatment is better than no treatment. But when possible, try to explore different options if it looks like they may need some. Making referrals to other providers who provide rewards for referrals, otherwise known as kickbacks. Totally illegal in most states. I've cited Florida statute here. I'm licensed in Florida, so I'm most familiar with Florida statutes with regard to that. But paying a kickback, rebate, bonus, or other remuneration for receiving a patient or client. So getting some. Paying somebody something for referring to you or receiving some of those things for referring a client is considered illegal in the state of Florida. What is a kickback, though? A kickback? The state of Florida defines it as the payment of a non, when a payment is non tax deductible, as an ordinary and necessary expense. So maybe you went to visit this treatment center to learn more about it before you sent your clients there and they paid for your hotel and your lodging and your travel. Technically, that's not a kickback. But if you start referring clients there and then at Christmas time, all of a sudden you get, you know, some very luxurious blanket or a gift card to somewhere. Now that is not an ordinary and necessary expense that would be qualified as a kickback. So the key is, is this something that, you know, if they didn't pay for it, I would be able to deduct from my taxes as a necessary business expense. Don't encourage patients to opt for a higher level of care, which would pay the company more. Don't encourage patients to enroll in a treatment program with the insinuation that copays and deductibles will not be collected. It used to be that this was only an issue or only a prosecutable issue with Medicaid and Medicare. But under the current insurance thing, most of the private insurance companies have also now jumped on the bandwagon and are enforcing and prosecuting people who do this with private insurers. So you don't necessarily have to say co pays and deductibles won't be collected. But if a client comes in and finds out they have a $6,000 deductible before insurance will pay anything, and they're like, well, I can't afford that. I'm gonna have to go somewhere else that's cheaper. And the person doing admission says, well, don't worry about it. We'll work something out. You know, I understand that's a lot of money. Just let's get you started. And you don't have to worry about this. Then the word may start getting out, especially if that's followed up by the organization either not even billing the client for those. Most of the time, organizations will bill the client. The client will come in to the organization and freak out and go, you told me not to worry about this, and I just got a bill for $1,200. And the organization will say, don't worry about it. They'll try to contact you three more times to collect and then they'll write it off. Now this is never put down anywhere in writing, but it's sort of said with a wink and a nod. If this gets out on the street, as it's one of your standard operating procedures, even if it's not a written one, it could cause the organization to be investigated and lose their ability to provide services to people with that insurance. The other problem is if you engage in this practice and the client's like, okay, so you'll try to collect three times. When I don't pay, you won't follow up and turn me into collections. Okay, I can do this, no problem. I'll just throw them in the trash. Then all of a sudden your administration changes and the new administration says, we're going to collect on everything. Well, now the promise that you made or insinuation that you made that the client will probably take as a promise is invalid and they're going to be very, very angry. And that may cause a lot of other problems with inability to trust providers and you know, yada yada. So if you sign up with insurance companies, know what their level of care guidelines are, know what you have to provide within that level of care, and know what the contractual obligations are with regard to your ability to discount, waive or, you know, otherwise handle co pays and deductibles, avoid using techniques in which you are not adequately trained. Even if the state doesn't require a specialty certification. In most states, hypnosis is, you're required to have a specialty certification, as are sex therapy. But with child therapy, eating disorder treatment and addictions treatment, most states don't say anything about requiring special training or certification in order to treat people with these issues or of this age. As long as you're happen to be licensed, I will tell you from experience, I am not trained or capable or ethically equipped to do child therapy. That's just not where I have training. And children are not little adults. So it's unethical for me to see children without getting more training and supervision. Eating disorders are not just addictions. So, you know, there are special treatment protocols that people use with eating disorders. There's no special certification required. And addiction itself, a lot of clinicians will work with people with addictions without having any training in addictions. And some of the things that I hear that bother me the most are, well, once we start addressing your mental health issues, your need to use that addictive behavior will just spontaneously go away and it makes me want to pull my hair out. So if there is a disorder that you are not trained in working with, be upfront with your patients and or your supervisor with the child. Therapy. At a place I used to work, there was a period where I was supervising the children's in school therapy program. Now supervising is different than providing hands on therapy and thankfully I had some, some mentors. But there were a couple times where I had a clinician out and I had to make the decision about do I go in and do therapy with this child not knowing what in the world I'm doing or do I let the school know that I won't be there today? And obviously I chose to let the school know I wouldn't be there because in my estimation it would do more harm for me just to show up and go, hey, let's color. Don't provide prescriptive advice in an area in which you are not trained. Most states, not all. You know, I haven't looked at all regulations, but most states will very explicitly say you cannot provide nutritional guidance, nutritional prescription to patients unless you are a registered dietitian. Now you can hand them a book and go. You might find this interesting, but you can't create a meal plan for them. You can't do something that would basically be considered a treatment plan. The same thing is true with medicine, supplements or even exercise. A lot of us say, yeah, it would be great for you to start getting some more exercise because it releases serotonin, it's relaxing, yada yada. However, it's important that you make sure the doctor says it's okay first and you talk with your physician about how much is okay. Now, honestly, most clients don't go to the doctor and go, okay, can I go to the gym? They just start walking. But it's imperative that we do not start prescribing things like this for them that are outside of our scope of training. Beneficence means taking a proactive action to improve client welfare. Love doing those things. Non malfeasance means ensuring that above all you do no harm. Harm to clients is often incidental to a clinician's actions, often designed to get more money. Clinicians usually don't go, hey, I'm going to go out and try to make a client hurt today. That's not what we do. But a lot of times a clinician's personal motives override better judgment and they incidentally or accidentally hurt clients along the way. This can be done with insurance fraud, referring to agencies with the best kickbacks, or referring to agencies with this quid pro quo arrangement. If I refer to you, then you're going to refer to me and they keep tabs on well, I've referred three people to you, so where are my referrals? Failing to discharge a reliable client and encouraging participation in an unnecessarily high level of care so the agency can get a higher reimbursement level. Ethically, we should strive to prevent people from becoming clients in the first place. Provide prevention activities or information. You can do this in groups, you can do this in educational seminars. You can do this in a lot of different ways and even get paid for it. Encourage people to seek help at the first sign of distress to prevent larger problems Prevent or provide effective, efficient services to empower clients to take charge of their own mental health and physical health and ensure knowledge of a wide arrange of techniques and referral sources to meet the individualized need of each client. And if you don't have the techniques or the skills to meet that client's specific needs, then refer. You know, none of us knows everything, so be willing to refer when it's in the client's best interest. Are there any questions? 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