Ethical Considerations and Risk Management

In an attempt to preempt a negative answer to the question, who do we think we are? The various professional organizations involved in mental health treatment each have a set of ethics guidelines (e.g., the American Psychological Association and the American Psychiatric Association). These guidelines are designed to help clinicians avoid, or at least manage, serious problems with patients and to practice in a manner that ensures the utmost professionalism. Ethical practice is good practice. Ethical practice is safer practice. Regarding the issue of clinician mental health, healthy practice begins with ethical practice.

Ethical practice begins with knowledge of ethics guidelines and principles. A clinician must also know who his or her client is and the parameters under which they work, whether it is in private practice, an institution, a government agency, and so on. Sometimes ethics and law collide or contradict each other. Ethical and safe practice must also include a working knowledge of the specific risks for working with specific clinical issues and populations. For example, I learned early on in my training that if you are going to work with children, you are going to face a child abuse-reporting situation eventually and sometimes often. Various populations bring their own risks. Working with Personality Disorders may involve constantly managing suicidal or self-destructive crises. When working with PTSD patients, risks may include strong countertransference reactions, burnout risk, emotional contagion, being involved in litigation and legal proceedings, addressing repressed memories, and mandatory reporting issues. There may also be particular risks for finding oneself involved in political issues and causes related to war, torture, and human rights. In the spirit ofJudith Herman, sometimes with trauma, it is hard to remain neutral. She states, "It is morally impossible to remain neutral in this conflict. The bystander is forced to take sides" (p. 7). (For more on this topic, see the section on therapist neutrality later in this chapter.)

Although not specific to PTSD, Thomas Plante (1999) provides 10 strategies to avoid "ethical and legal perils" (p. 1):

1. Always obtain informed consent. This includes information on the parameters of the services provided, the nature of the professional relationship, potential risks and benefits, limits to confidentiality, and relevant financial issues.

2. Get arms-length consultation. This is consultation with a professional who has objective distance from the situation.

3. Maintain professional competence. Plante identifies this as fundamental.

4. Know the law and ethics code.

5. Avoid or plan for high-risk patients and situations. Certain populations are more likely to generate ethical or legal complaints such as divorce or child-custody evaluations, repressed memory, Dissociative Disorders, and Borderline Personality Disorders.

6. Do not use collection agencies.

7. Keep good written records. Minimally, these should contain identifying information, assessment results, consultation and summary reports, diagnoses, treatment plans, progress notes, dates and types of services, fees, release of information, and detailed information about suicide or violence risk.

8. Maintain confidentiality.

9. Be extra careful with managed care and insurance companies.

10. Get help when needed. This includes informal consultation, formal consultation, and legal consultation if necessary.

Now let's turn to issues specific to working with PTSD sufferers.

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