Ethics Part 5

Hi and welcome to Ethics Part 5. This is the fifth and final segment of our five part Ethics series. However, you can view this and not have to have watched the first four parts in order to understand what's going on. So if you just need a little bit of ethics, you can start here. This is brought to you by allce.com and we will talk more about how to get CEUs for this presentation at the end. Today we're going to talk about bartering, gifts, the benefits and drawbacks to diagnosis, testing issues and miscellaneous common ethical violations. So we're going to start with bartering. Bartering is the exchange of goods or services between people. What's the problem with it? If I want to see a client and she wants to give me a dozen eggs in exchange, what's the problem? Well, the definition of the value of goods or services and the risk of impaired judgment. So let's think about the value of goods and services. If it's goods, it may be less difficult to quantify than services. A dozen eggs is pretty much what that goes for in the grocery store. A gallon of milk. So if you work in a rural community, bartering is not that uncommon. But there are a lot of things that you need to do in order to protect yourself and the patient. Now take for example, maybe you live in an urban area and you have a client who is cleaning your office for you or cleaning your house for you. Well, that's a dual relationship in and of itself. But you know, we won't go there right now. That's part four if you want to go look at dual relationships. But if they are performing a service for you, then you've got to quantify that service. So mowing my lawn for me is X number of dollars. So you mow my lawn once, I will see you once. We'll say it's an even Steven trade. Now, if either one of you disagrees about the value of services, maybe your client says, well, mowing your lawn is worth $120 and you only provided me, you know, a service that was worth 40, you were off your game today. Or likewise, you're providing counseling services and you're on your game and Jim Bob comes over and mows your lawn and you're like, you didn't edge, you didn't weed whack, you didn't trim the bushes. What are you thinking? This isn't worth what I gave you. So there are a lot of issues involved in subjective services that are being provided. Unfortunately, our services are almost always subjective because it's difficult to quantify how good your counseling is, except for by the patient. So Recommendations Evaluate whether the bartering arrangement increases your risk of impaired professional judgment. Maybe the patient who is cutting your lawn is doing a really good job and you know good and well it's probably worth more than what you're exchanged for. And you don't want to lose this patient, this person doing your lawn, but you also don't want to pay them, so you just drag them along in therapy. So unethical. Okay, so you see where judgment can be impaired if you want to keep the patient doing something, or likewise, if the patient isn't doing a good job or the patient is a challenging patient and you don't want to see them anymore, you may have difficulty navigating that Determine the value of the goods or services in a collaborative fashion with the client at the outset of the bartering arrangement. Specify what he or she will do. Specify what you will do. Keep your appointments. Be on time. See them for X number of minutes. Write whatever reports. If there are reports. Define what you're going to do and determine the length of appropriate time for the barter arrangement. Usually it's best to reevaluate once a month. The patient can generally get a feel over the course of a month of whether they're improving or not or whether they're liking this arrangement. Identify the date on which the arrangement will end or be renegotiated if a misunderstanding begins to develop. The matter should be dealt with by a mediator, not by you and your client. There's too many dynamics there, and that gets into that whole dual relationship issue. You need to bring in an impartial third party to figure out or help you guys navigate what's going on. With permission from your client, it's a good idea to tape record, preferably video, the discussion of the arrangement. That way nobody can say, well, I never said that or I didn't do that. Have it recorded. Now, moving away from bartering considerations for giving or receiving gifts, consider the monetary value of the gift. And this is a good thing to go over in your intake paperwork because it is common for patients to want to give you gifts. However, is it ethical? Consider the monetary value. Where I used to work, anything more than $5, we weren't allowed to accept. Tell them that at the outset. Help them understand that for legal reasons and because of company policy, you aren't allowed to accept any gifts. The clinical implications of accepting or rejecting the gifts. Now, if you have a gift and say it's $5 it's right on the borderline. But you're working with a juvenile patient who made a painted coffee mug for you that you know is 850 even. Do you reject that? This coffee mug that the client painted for you, that said number one therapist? And you're like, oh yeah, what are the consequences of rejecting that to that child's psyche? What are the consequences of rejecting the gift if an adult does it? You need to look at it in terms of each individual client as well as the culture of the client, how long you've been seeing them and where they are in their treatment. What are your own motivations for accepting or rejecting a client's gifts? If a client happens to own a bakery and starts bringing by baked goods every morning, is it ethical to let him or her do that because they're doing it as a kind gesture? Ethics would say, no, it's not. You really appreciate it. But if they're doing it every day, it's going to be way over that five dollar mark. And it also sets up a difficult dynamic. A client may start believing that you owe them something if you start accepting their gifts regularly. What are the cultural implications of offering a gift or of accepting a gift? If a client offers you a gift, is that a cultural tradition? Is that something that would be offensive if you said, oh no, I can't take that. Maybe it's something from their heritage that they want to share with you. One of my clients one time made in our art therapy class a dream catcher and gave it to me. That was very important to her. It was very significant to her. Again, it was under that five dollar limit. We talked about what that meant and what it meant for her to make it for me and to give it to me. So we processed it as a therapeutic issue and talked about how that might translate into her relationships outside of residential treatment. Okay, so enough said about that diagnosis can be your best friend or your worst enemy or both. It enables third party reimbursement most of the time. Sometimes you find one of those diagnoses that the insurance company doesn't cover and then you're like, oh, crap. But with or without that little number in the dsm, the insurance company would reject it if it's not something they cover. I explain it to my clients as it provides a convenient shorthand for us to use to communicate. When you go to the doctor and you say I've got a cold, that communicates a fair number of things to him from the get go about what things to start asking about. He's not going to ask about stomach pain and back pain and whether you've got numbness down your leg. He's going to ask about fever, runny nose, coughing, those sorts of things. If a client comes in and says, I'm depressed, I'm not generally going to start out asking, well, do you hear voices that tell you to do things or are you drinking an excess amount of alcohol? Eventually we may get to those. If it looks like the depression has some psychotic features or there's concurrent substance abuse, but depression itself doesn't come, come out and say, let's look for these. You would start asking about, how are you sleeping? Have there been changes in your eating patterns? Do you feel hopeless and helpless? Do you just not find anything pleasurable anymore? Go on with those. Look at how long those have been going on. So it's a shorthand. And a lot of times now I'm not as comfortable with the DSM 5 as I am with the DSM 4. But. But I would pull out my DSM IV and we would go through the diagnostic criteria together and I would say, okay, criteria number one. Does this fit? Does this fit? It was very objective. It was like doing a checklist. When they went to the doctor to say, these are the symptoms I'm having provides a list of symptoms which can individually be identified as objectives in resolving the main problem. Appetite disturbance. Does that always mean depression? No, it can mean a whole realm of things, mental health and physical health. So it gives us a place to start and we can say, all right, you're having some appetite disturbance. You're eating all the time. Tell me what that's about. Are you eating because you're hungry, you're bored, you are craving a certain salt sweet something. You can start there and use it as a treatment objective to normalize for that patient. And everybody's eating patterns are a little different, but get it back to what that patient perceives as normal for him or her diagnosis. Also can assist in demystifying the process of counseling and diagnosis by demonstrating to the client the diagnoses are simply a shorthand to refer to a cluster of symptoms. It's a lot more effort if I have to call Dr. Smith and go, okay, I'm treating your patient and these are the 18 different symptoms he has versus saying your patient is experiencing major depressive disorder with appetite and sleep disturbance. Lot shorter that way. And communicates the basic information. And if Dr. Smith wants more detail, then I can certainly provide that. A lot of times Dr. Smith says, thank you very much. Click diagnosis can be useful that way. However, it can minimize the uniqueness of the client. The client may start to feel like every other person with depression. Well, my friend Sally down the street had depression and she didn't feel like this, so I'm not depressed. Well, no, depression is different for everybody. Just like if you're in the same household. We just went through an upper respiratory thing in our house and every single person had slightly different symptoms. So did we have the same cold? Probably. But it manifested differently in each one of us and we just happened to pass the same germ around. Diagnosis focuses on symptoms, not solutions. We've really moved towards the solution, focused treatment planning. So if you're focusing on problem sleeping, let's fix the problem sleeping. Well, how can you say that as a solution? Improve sleep quality. So we're focusing on trying to help the person improve and improve the sleep quality instead of remove the problem with sleeping. Semantic. But it's important. It emphasizes deficits, limitations and symptoms. We really want to look at strengths, abilities and solutions. May discourage people from finding and utilizing their strengths, competencies and abilities. I feel hopeless and helpless. Okay, how do we make that go away? I don't know. Okay, then you're stuck. If the person says, I feel hopeless and helpless and you say, all right, tell me about a time when you didn't feel that way. What was different when you start to feel hopeless and helpless because, you know, it happens to all of us. We have periods where we may get depressed. Maybe not to the same level that you feel right now, but when you start to feel like you may be getting depressed, what do you do to cheer yourself up or help yourself get out of the funk? What are you doing differently now that may be contributing to it? Look at what the person's done in the past. They've been living in their own skin for decades. They probably have a better idea about what helps them move out of that state than you do. Having only known them for 15 minutes, it may discourage people. Yeah, I read that one. And can lead to self fulfilling prophecies. Some people own a diagnosis. Instead of saying I have depression, they say, I am depressed. I am an alcoholic. I am a bulimic. Okay, well if we help you get rid of that because you are saying you want to get rid of it. So if we help you get rid of that diagnosis of being bulimic or being depressed, then what are you? How do you finish the I am statement? Again, it's a small element of semantics, but it's like the difference when you punish if you will a child or correct a child, and you say, I really disapprove of that behavior instead of I really disapprove of you. Semantics. But very important, it can narrow therapists vision by encouraging them to look for behavior that fits a certain category. For the longest time, a lot of therapists, when they saw somebody who was depressed, looked for those symptoms of depression they're finding now, which, you know, a lot of us knew a long time ago that depression and anxiety often co occur. So they got so focused on looking at the depression that they didn't look at symptoms of anxiety over here. They were like, didn't even ask about them. Look for both. Get a full psychosocial history to see what's going on with the patient. And then you can do the House thing and try to figure out what diagnosis currently fits them best. Better yet, ask them what of these symptoms that you've got going on right now? What is it that you really are most motivated to work on and what are you hoping to get out of counseling? Try to look for something that they're trying to add or change for the positive, not something they're trying to eliminate. Diagnosis is often not multiculturally sensitive. We know from the beginning of diagnoses when they were talking about neuroses. It doesn't take into account individual or cultural differences in the expression of emotion and the experience of interpersonal relationships. And as often and too often used by persons who do not possess the competence to make a diagnosis. You have someone who is doing a screening who may be identifying and ruling in or ruling out depression. It may be being used, and most state laws are starting to clamp down on who is allowed to and who is not allowed to make a diagnosis. But it may be being used on people who haven't been adequately trained how to diagnose things. One way you can possibly improve your diagnostic reliability and validity is by using some objective tests. The Beck Depression Inventory, the Staxi, the Addiction Severity Index. Whatever type of problem you happen to treat, there's probably an inventory or a test out there. However, you need to make sure when you pick tests, even though they look really cool, you have to identify what the test is supposed to measure. Weigh that against the benefit of doing something else with that client's time. If you're just using this test and you already know the person is depressed and significantly depressed, Major depressive disorder, and you administer the Beck Depression Inventory, unless you're using that to monitor progress, is it worth having that instrument in the file? So make sure you know what the test is supposed to measure? The groups on which the tests were normed. If it was normed on college students and you see a geriatric population or an adolescent, young, adolescent population, it may not apply. The questions may not even be appropriate for those age groups in order to identify the symptoms that you're looking for. Their generalizability. If it was normed, maybe it was the same age group, but it was normed on all white males between the ages of 25 and 50. And you see a very multicultural, multiculturally diverse set of clients, it may not be generalizable. How valid are those tests? Go back to those norming tests and say when they were compared to other tests that measured the same thing, were you comparing apples and apples, or is this a hit or miss whether it's accurately going to identify whatever you're looking for and their reliability? If you give this test to people who meet the criteria for depression, if you give it to 10 people who meet those criteria and it's supposed to measure depression, and you're assuming you've looked and it's normed on the population on which you're administering it, and all that stuff, and you follow the directions, is it going to pick out all of those people as depressed, or is it only going to be like a 60, 40, hit or miss sort of thing? You want to pick tests with high reliability, high validity that were created for and normed on populations that are similar to your population and generalizable. Now, again, with generalizability, there are a lot of factors. Urban versus rural culture, ethnicity, age, whether they have English as a first language or a second language. There's a lot of things you need to consider. Above all, don't use tests in isolation to make any judgment. Know your codes of ethics with respect to competence in working with tests. Don't administer tests that you're not competent to administer. Have a clear rationale for the reasons you administer certain tests. If clients request testing, it's imperative to discuss the benefits and drawbacks and limitations of any tests. A lot of patients will come in and they want to be tested for ADD or anxiety or whatever the case may be. ADD is the biggest one that people want to be tested for. So you really need to have an open discussion with the patient about what are you hoping to get out of this, and these are the limitations and the advantages of the tests that are available. When selecting tests, it's important to consider how the test results will be handled, including whether they need to be sent off to be scored. If the client wants immediate gratification and you've got to send it off and wait six weeks. That's not going to work. If you need feedback right now and you've got to send it off and wait six weeks, not going to work. What's the test going to be used for? Is it going to be presented in court? Is it going to be used just for the patient's own knowledge? Is it going. How is the test going to be used and for what purpose? They should never form the sole basis for any assessment. Clients should be informed about what each test is intended to discover, how it relates to the situation and how the test results will be used. The client's like, why am I filling out all this paperwork? You need to have a rationale. Well, this helps me monitor your progress with regard to this particular diagnosis or symptom. Whatever your rationale is, explain it to the client and how that test is useful to them. Tests should always be placed in proper perspective within the context of other relevant factors. Back depression inventory, addiction severity index, etc. You can get scores on any of these tests that indicate there's a problem or not a problem, but you have to take into account all the other psychosocial factors. Maybe the score on the Beck Depression Inventory doesn't indicate that they're significantly depressed, but you're looking at the patient going, oh, you're significantly depressed. And here are all these factors, risk factors that are out here. You may need to take a look at that. Maybe the language in the test isn't the same language that the client uses. Whatever the case, it's a piece of paper. Yes, it's normed. Yes, it gives you a good idea. But there's also a reason you went to college for like a bazillion years. So once you diagnose the client, because you're going to the four major areas where ethical dilemmas most commonly surface in managed care, and I use this term very broadly to incorporate private as well as private insurance as well as Medicaid, Medicare, etc. Are informed consent confidentiality, client abandonment and utilization review. Economics, funds and fictions 1 frequent but unethical practice is to alter a patient's diagnosis in order to ensure compensation for managed care. Two examples upcoding would be, for example, a client presents with symptoms of adjustment disorder and you diagnose the client with major depressive disorder or generalized anxiety disorder. So insurance will pay. Not ethical. They don't meet the criteria, they don't get the diagnosis. Flipping in this world day of co occurring Substance abuse and mental health disorders. Sometimes agencies will bill under one diagnosis until they exhaust all those benefits and then they will flip and put the other diagnosis as primary so they can bill under those benefits. Does it happen that sometimes once the patient's substance abuse remits that their mental health issues start to go up? Yes. Is it possible? Yes. If you're doing it solely for reimbursement, there may be some significant ethical and or legal issues there. Consult your lawyer, consult your accountant. Another unethical practice involves failing to identify the addictions diagnosis in order to prevent stigma or repercussions for a client. And I should include addictions or any access to diagnosis. A lot of times patients will be like, I know I've got a problem, but I really don't want my employer to find out. I really don't want this, that or the other. Please don't put it down. Not really ethical. That is a quandary that you need to discuss with the client and decide for yourself what post poses greater harm. A challenge for many programs is the lack of reimbursability for family based services to treat a disease which is often systemic or family based in nature. A lot of things are systemic and family based in nature. Oppositional defiant disorder, substance abuse, PTSD related to abuse or incest in the family. There's a lot of stuff, but a lot of insurance companies don't reimburse for family care. The one thing that I can say that I'm happy to say is in recent years I believe every insurance company that I work with indicates that families need to be involved in the treatment of their loved one who has a substance abuse or addictive disorder. And if they are not involved in face to face sessions, family sessions, then there needs to be a clear clinical rationale for why that's not happening and an alternative agreed to. They're really identifying that substance abuse and addiction may have a family component, which is awesome. It really helps create that supportive environment for the patient and the patient's family to recover. However, we do have issues of exploitation. Financial exploitation occurs in the alcohol and drug abuse field because many recovering addicts are unable to think clearly for months or even years after ceasing use. So where I see this happening most is where clinicians either keep the client in therapy longer than they need to or they send the client for unnecessary tests because they can. And that's an abuse of power as well as exploitation. Exploitation in the form of publicity can occur for social as well as financial gain. So if you make someone a star client. In some states, they prohibit you from using clients in advertising and things like that because they feel it puts the client in an uncomfortable position where they might feel like they're not able to refuse to provide a testimonial. So some states have gone that step and said you can't force clients to provide testimonials. Social contact with patients may result in exploitation due to a dual relationship. Again, go back to part four if you're actually part three if you're interested in the dual relationship issue. But I think most of us have that pretty clear. Sponsorship of a patient in a 12 step program by the therapist is strongly discouraged. Why? Well, basically for the same reasons that you don't want to be friends with your clients outside of your therapy relationships. It creates a dynamic where you may either cause dependence or be less confrontational than you should be. In the therapeutic relationship. The client needs to learn how to reach out and develop sane, sober social supports on the outside in addition to the support that they've got with you in the therapy room. Current trends often place counselors in precarious positions due to a lack of sufficient different levels of treatment. Therefore, they're faced with over treating, putting somebody in residential or under treating, putting them in traditional outpatient. You have a client that comes to you and you know they need significant supervision. Partial hospitalization, eight hours a day, five days a week would be ideal because then their mom can come down and stay with them, or their spouse will be there and not be at work on the weekends and can provide weekend supervision. But right now they're having a sufficiently difficult time functioning that they could use some supervision during those times when they don't have anybody that they can lean on. Partial hospitalization would be ideal. Those programs are very few and far between. So you have to look at, well, do I refer them to iop, which is only three, three hours a day, three days a week, or do I believe that that would actually help them, or does it put them in harm's way? Or do I refer them up to residential, which is a little bit more intensive than they actually need, because when somebody is with them, they seem to be relatively stable. Unfortunately, we have to make that decision sometimes to recommend a level of care, and again, it's almost always up to the client, unless you're initiating involuntary commitment. Many organizations try to upsell clients to the next higher level of care for reimbursement reasons. Now, if you're seeing a client and they probably require multiple sessions a week of outpatient, but you're trying to upsell them to residential because you'll get paid more. That's just unethical. If they don't need residential, if that's not the least restrictive environment, then they don't need residential. Many organizations aggressively recruit patients who are private pay or out of network recruiting patients who are private pay because you don't have to go through all the filing and everything. That's a choice. That is a choice. If you're recruiting out of network patients, you still have to do all the filing. But a lot of times organizations will do that because they really jack up the price of the services. So they get paid a whole lot more for being an out of network provider than for being an in network provider. For an example, an IOP day for an in network provider, intensive outpatient, a provider may get paid $135 for out of network. They may get paid 640 just because they're out of network. So you can see why people may want to go to out of network. But then there's all kinds of other legal and ethical issues that we'll talk about in a minute. In order to get higher insurance reimbursement, many companies waive copays and deductibles for that out of network patient and accept insurance only. I found an excellent resource on the Internet. It was a PowerPoint that was done on this specific topic that really talked about the legal issues and the case law that was germane to waiving co pays and deductibles. Now most insurance companies will tell you that's not okay. If we pay you 600. Let me do the math in my head. We'll just use round numbers. If we pay you 60% of your billed charges and that's $600, then the client owes you 400. If you don't collect that 400, then what you're saying is your services were really only worth 600, so we should be paying 60% of that, which is a whole lot less money. So you really need to look at the legal and ethical implications. And I will caution you that it is really coming about a lot more lately that it's not just Medicare and Medicaid where this can become a real issue and bite you in the butt. There is case law pertaining to private insurance companies that are going after providers for waiving co pays and deductibles or saying that they accept insurance only. Whatever insurance will pay is what we'll take. So another special case is when you look at hiring an alcohol or drug abuse counselor to work in your facility, you need to consider their level of experience. If the counselor has a prior history of addiction, they should be sober for at least two years. The reason the person is in the field, whether the person has or has had a family member with an addiction problem and how they dealt with that issue and their theoretical orientation. Now, that doesn't mean that if somebody has been in recovery, you can't hire them. It doesn't mean if they've got a family member who's been in recovery, you can't hire them. It just means you need to get a good understanding of where that person is actually coming from and how they're going to interact with your clients to make sure that they've got the boundaries and the knowledge to provide the best, highest quality of care. So, in summary, with due diligence and a little common sense, most counselors have no problems adhering to ethical and legal guidelines. If your head says it's okay and your heart says it's okay, and your gut doesn't go, oh, probably fine. But when in doubt, consult. Remember, if what you are doing feels wrong or unfair, or if you have to be carefully coached on what to say, it's probably at the very least unethical, if not illegal. And you need to run it by a colleague and or your attorney, depending on the issue and what you're dealing with. All right, thank you for attending today. CEUs are available@allce.com they are NBCC, NAADAC, CADAC, and California Board of Behavioral Sciences approved. This course is also accepted in most states under our NAADAC approval for addictions counselor pre certification credit. All right, thank you and have a wonderful day.