You did what? Avoiding Common Ethical Violations in Counseling

All right, I do want to do a little bit of part eight. We don't have to do the whole thing because I. I clearly have been more talkative than I expected, but I do want to apply some of these ethics to common ethical violations and kind of wrap things up a little bit. Remember, the seven ethical principles are non maleficence, beneficent. So do no harm and do what's good for the client. Actually proactively do good. That means advocacy. That means education. That means, you know, not just reacting and doing no harm, but proacting justice, which means making sure everybody has equal access to equitable services. You, anybody, regardless of their race, color, religion, socioeconomic status, sexual orientation, has access to high quality mental health services. Autonomy, making sure clients have the ability to speak for themselves, to advocate for themselves, and to participate in their treatment process. Veracity means doing what you have to do, even if it's uncomfortable or hard. Fidelity means keeping promises and being faithful to your agreements. And accountability, self explanatory. Now, your four pillars are non maleficence, beneficence, justice and autonomy. Veracity, fidelity, and accountability. You can kind of squeeze into those otherwise, but depending on which book you read. Remember the ABCDEs in ethical decision making. Assess the problem and the impartial, generalizable, and just justifiable options to address that problem. The short and long term benefits and consequences of each of the options. Decide on a course of action, evaluate outcomes, and seek consultation. So in the following scenarios, however many we get through, assess how this issue, whatever this ethical issue is, might have arisen. What would have caused this? How could a clinician have gotten into this position or what would have prompted them to make this decision. Think about the various benefits and of the short and long term options for addressing the problem and the consequences, identify the best course of action. You know, if you're presented with this situation, we know the wrong choice is to do this over here. But if this situation arises, what are your other options besides this ethical violation over here, and which one is the best course of action and why? So, number one, still, number one, sexual relationships with clients. So the scenario a client begins, a counselor begins dating a client they've been seeing in therapy sessions over the past 18 months. Well, number one, they're currently seeing the person in therapy. That. That's an issue in and of itself. But what might prompt a clinician to start dating somebody who is an active or recent client? And I think I have y'. All. So you can actually turn on your. Yeah, you can turn on your microphones if you want to, or you can type. I'm good with either. Sexual addiction. That is a good observation. If somebody is experiencing sexual addiction, we know that's a symptom of an underlying problem, but then they are trying to meet their own self medication needs by exploiting the vulnerable client. They have their own problems, especially unchecked feelings toward the client. And no action was taken. Do you remember the Johari window from counseling? You had that diagram and it had four blocks. The first block was what you know you're aware of and everybody else is aware of. All right. Then there's this block over here you're aware of, but nobody else is aware of. Like you may be aware of your feelings toward the client, but nobody else knows. And you're like, I'm just going to try to push this down. This one down here is what everybody else knows, but you don't see yourself. Everybody else can see that you've got some ethical boundary issues going on in this relationship, but you don't see it. And then the fourth window is stuff that you don't see and nobody else sees. And it kind of bites you in the butt when it actually comes through the window. But it's important. When we start getting burned out, we can. Or if we're having drama or trauma in our life, it may feel safe to engage with a client who pose with a person who poses no threat, who's already made themselves vulnerable. If we are needing to be needed, if we are being codependent, we may cross over that boundary. So it's really important to regularly assess your feelings toward clients and make sure that you are seeing them and you're providing treatment based on what's in their best interest and you're keeping your own stuff in check. A breach of confidentiality is another very common violation. Example, a counselor comes home and tells their spouse details about a client's marital problems that were disclosed in a private session. Now, I think there are a lot of clinicians that go home and talk without revealing client information, client identifying information, and they debrief with their spouse. Now, spouses can't be forced to testify against their client, their, their spouse or whatever. But ultimately recognizing if you are decompressing, if you are processing what happened during the day, there's probably better ways to do it, like with a colleague or with a supervis recognizing if you do talk with your spouse about your day, making sure that there is absolutely no identifying information. And I don't know how big the city has to be for you to Feel comfortable that just eliminating the name is going to protect the client confidentiality. I don't think it's probably the safest thing to do, but, well, there. I have clients who come up to me in Sam's club. I've had clients come up to me in Sam's Club and give me a big hug and oh, Ms. Dawn, I'm doing so well, I got my kids back or whatever and I'm like, ah, great. But they approach me, they tell me whatever they want to tell me and you know, I try to excuse myself as gracefully as possible or you know, I, I definitely make sure I don't re reveal any confidential information. There's also issues if you're in a very small town of if you get a check from your client, some people still actually do use checks and the check goes to the bank and the person at the bank sees that. Sally Smith went to see, went to see you and keep seeing these session notes. He's like, oh, Sally, Susan therapy. So that can be problematic. Likewise, there is some discussion in the high tech forums about your business name. When you do a credit card transaction, the credit card company knows that the person saw Dr. Snipes. Now they may not know whether you're a podiatrist or a psychiatrist, but they know this, this person saw Dr. Snipes. Not everybody may be comfortable with that coming through on their credit card bill. And you know what happens if their spouse opens their credit card bill and they're trying to see you on the, on the DL. You know, there's a lot of things to consider about how people might in accidentally get their, their confidentiality breached. In smaller towns, people can also have their confidentiality breached when they come and go from your office. What responsibility do you have to provide a private entrance and exit for clients? And that's, that's a personal decision and part of it is based on where you're at. In Nashville, we had some high profile clients that we needed to make sure were able to kind of get in and get out because they didn't want everybody knowing their business. But. Back doors are excellent for professionals who want confidentiality, especially if it's in a covered garage so people driving down the street can't see. That's what we ended up doing. So that can be helpful. That way their car and their license plate is also not sitting out there on display for everybody to see. Identifiable information. And you can review this later, but until I taught the HIPAA class some years ago, I had no idea how much of the stuff could be identifiable names. Of course you take that out. Geographic details smaller than a state. Wow. So no. No zip codes, no street names, no city names. Those are all supposed to be redacted. All elements of date other than year associated with the person, such as admission and discharge dates, date of birth, date of death, all ages over 89 years old and elements of dates that indicate age, for example the year they graduated from high school Contact numbers, Social Security addresses, IP addresses. If your EMR EHR stores people's IP addresses that needs to be redacted before that information goes out. Bank and credit card account numbers. Those are create an identifiable trail. So those should be redacted when you are blacking out the information. Vehicle identifiers and full face photos and comparable images in some treatment centers there is the practice of having people have ID badges. I know they were doing that when I left Meridian a decade ago or so. That way the nurse could easily identify the person that was showing up for meds was the person she was supposed to give the meds to. Key update CFR 42 part 2 I know one of you is in a CFR 42 facility in 2024. The the this update was released in April of this year. Allows a single consent for all future uses and disclosures for treatment, payment and healthc care operations. So you don't need 50,000 disclosures. It restricts the use of records and testimony in civil, criminal, administrative and legislative proceedings against patients absent patient consent or court order. I thought that was always in there, but it's definitely reiterated now. It aligns the Part two penalties with HIPAA violation penalties, which can be pretty significant and applies the same requirements of the HIPAA Breach Notification Rule to people who are protected under CFR 42 part 2. It also adds an express statement that segregating or segmenting part 2 records is not required. So you don't have to have a separate substance abuse note and mental health note anymore. They actually can be the same note, but if you're required to release them unless you have a court order for both, you need to redact the substance abuse information. It introduces a new definition for substance use disorder counseling notes. These are analogous to but not the same as HIPAA psychotherapy notes and require specific consent from an individual from your client and cannot be used or disclosed based on a broad court order. And we'll do one more Practicing out the side of the scope of competence. A counselor who specializes in anxiety disorders attempts to treat a client without proper training. So as I said earlier, we're trained in general, as generalists, in, in graduate school, and hopefully in your internship, you developed a specialization. But there are still certain things that you may not be properly trained to treat. Schizophrenia. For example, working with somebody who is actively psychotic requires unique awareness of prodromal symptoms and how to work with somebody who's in a psychotic episode. If you're a licensed clinician, if you're a generalist, if you've got somebody with schizophrenia on your caseload, it's possible to get supervision when seeing this client. But recognizing that you do need supervision is important. Treating eating disorders. If you, you know, eating disorders exist, but you say, well, you know, eating disorders are related to trauma and if we address your trauma, then your eating disorder will just magically go away. No, no, that's not the case. And it's important. I actually had a therapist tell me that once. It's important to recognize the potential physical danger that somebody with an eating disorder, whether it be anorexia or bulimia, is, is in treating children. They are not little adults. You cannot do an hour of talk therapy with an 8 year old. I just, I don't think anybody would. But understanding techniques that can be used safely with children is important. Using dolls and other training, other techniques with children also has to be used with care, especially in trauma survivors. I know there's a lot of research out there about implanted memories and false reports that developed as a child's memory sort of morphed and got confused with other input and, and again, I haven't worked with children in over a decade, but I know working with people at the child advocacy center, they are very careful about who they allow to interview the children and how it's done. And as I've mentioned multiple times, emdr, you don't just say, hey, sounds good, let me try it. I read a book because you are actually working to help somebody sort of reprogram and that traumatic memory, it can be dangerous, unethical billing practices. Okay, we'll do one more. A counselor bills insurance for 60 minute sessions when they only provided 30 minute sessions. That's a big no. No, that's just straight out fraud. Billing for, in office sessions. When it's telemental health, some agent, some insurers reimbursed less for telemental health, or at least they did. So some providers were billing as if it were in person in order to get the higher billing rate. That's unethical and probably illegal too. And the other one that really gets under my, you know, self is when counselors or organizations or wave co pays or coinsurance on with regularity to individuals to get them into services. And then they basically overbill the insurance company. So if Jim Bob has a $5,000 deductible, some companies will wave that deductible and say, oh, don't worry about it. You know, we'll just see you for free until, you know, theoretically, you've surpassed your deductible. Then we'll just bill your insurance. That's not okay. Their coinsurance is the part of the bill that they're responsible for. And again, there are some agencies that will say, we're billing $1,000 a day for your services and your insurance company's paying 600. That's fine. Don't worry about your 400. That's not okay. That can get you into all kinds of legal and contractual hot water. There are a lot of common causes of ethical violations, including burnout, unreasonable financial benchmarks. Having to bill 30 hours in a week. I know. Can push people to try to stretch. Oh, yeah, I actually saw this person for a whole hour when in fact it wasn't. I. I've seen it happen, but it's not okay. We need to address the benchmark and not engage in the unethical behavior. Unresolved personal issues, especially codependency, need for acceptance, a lack of professional support, and overconfidence in one's abilities. Thinking that you can do anything with any, anybody that you're legally allowed to. No, you really can't. Self care and ongoing supervision and reflection, personal reflection are essential to preventing ethical.