Managed Care

Risk Management for Psychologists: Some Suggestions for Practice

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The practice of psychology presents a number of challenges for practitioners that, if not addressed appropriately, might lead to ethics complaints or malpractice suits. The very thought of such actions is stressful and for many psychologists, quite anxiety arousing. For some, mere mention of the Board of Examiners raises one’s blood pressure. But, with all the different laws and regulations, the ethics codes we’re supposed to follow, and the litigious environment in which we practice it can be a very confusing landscape. The fear of adverse consequences from disgruntled former patients can easily lead one to practice defensively. But, as will be argued, this would be counterproductive and a thoughtful proactive approach that incorporates competent, ethical practice into our everyday professional lives is recommended. While not all inclusive, the suggestions presented should help practitioners to practice competently and ethically while addressing risk management in a proactive manner.

Prevention

It is far easier to prevent a problem than to attempt to clean up a mess after it has occurred. It is hoped that this brief article will stimulate psychologists to establish practices and utilize strategies that will enable them to be proactive in each of the areas to be reviewed. This will likely prove valuable and avoid the need for the clear-sighted awareness that comes with hindsight.

Informed Consent

One important aspect of prevention is to ensure that patients and psychologists alike have agreed upon all applicable parameters of the professional relationship in advance. An essential element of ethical practice is the use of a written informed consent agreement at the outset of the professional relationship. All expectations, roles, responsibilities, and obligations should be clarified as early as possible. Consent should be voluntary, the patient should be competent to give consent (parent or guardian for minors), the written material should be written at a level the patient can comprehend, and we must assess our patients’ understanding of all that is agreed to. One does not want to hear "But I thought everything was confidential. I didn’t know you would report that" or " I never thought I would have to pay for that. I thought everything was included." For specific recommendations on what to include in an informed consent agreement two sources are recommended. Readers should consult the Ethical Principles of Psychologists and Code of Conduct (APA, 1992) along with their licensure law to be sure all legal requirements are met. An excellent model informed consent agreement that may be downloaded and modified for individual use has been developed by Bruce Bennett and Eric Harris for the APA Insurance Trust and is available at www.apait.org. But again, one should be sure all the requirements in any relevant State laws are met in any agreement used.

Work with Families

When providing services to families informed consent becomes perhaps even more important. All roles must be clarified to include custody arrangements, payment responsibilities, informed consent and assent (or minors), expectations of records release, and any anticipated limits to confidentiality. Clarifying in advance who is the holder of privilege is important. If possible, obtain written informed consent from each individual participating in treatment. Be sure to anticipate requests for records and treatment information in advance and include this in the consent agreement. Due to the adversarial nature of some family situations, advanced planning is important. Even when working with adolescents who may drive themselves to treatment and bring payment with them, it is important to include parents in the consent process and in treatment planning at the outset to ensure that all involved are in agreement with the treatment plan you propose.

Competence

No psychologist can effectively treat all patients, with all possible presenting problems, in all settings, with all treatment modalities. We must be aware of what the limits of our capabilities are and practice within our scope of competence. Competence is typically considered to be the result of didactic training, supervised clinical experience, and ongoing professional development. We should be stay abreast of developments in our profession and be aware of standards in each area in which we practice. While we all possess competence in certain basic skills, when specializing we should consult with colleagues with recognized expertise, and with published specialty guidelines to guide us regarding needed knowledge, training, and skills. Should questions arise later about why one provided particular services to a certain patient, this is what we would likely refer to. Psychologists should attend to self-care and ensure that distress does not lead to impaired competence. If we are unsure about this, consultation with a colleague who will give us honest feedback is recommended.

Documentation

Effective, thorough, and timely documentation will serve several key functions: It helps us to provide high quality services by serving as a reminder of each patient’s history, services already provided, assignments given, issues to follow-up on, and how patients participate in treatment.

It may be of great value if a colleague needs to provide coverage for us during periods of absence, if a patient returns to us for treatment at a later date after a period of absence from treatment, and if a patient returns to treatment at a later date with a different treating professional.

It may be of use to members of a treatment team during times when we are not present and questions about the treatment we have provided exist.

It can be very important for meeting insurance and managed care documentation requirements that must be met for utilization review to occur, and typically, for reimbursement to occur.

It is the tangible evidence of what transpired in treatment that will be used to demonstrate the quality of care provided should a complaint or suit be filed.

Effective documentation is an important risk management strategy. Not only have courts ruled that if it isn’t documented, it didn’t happen, but they have also held that an incomplete or inadequate record is an indication in itself of the quality of services provided. It is therefore important not only to thoroughly document all treatment provided, but also the rationale behind all treatment decisions made.

Requesting Past Records

Courts have also ruled that professionals who do not request and then utilize past records of treatment and evaluation that exist for a patient may be held negligent when to have reviewed these records would have provided important information for use in the patient’s treatment. We must collect a thorough history of each patient to include all past treatment and then request and then utilize any records that may be available.

Confidentiality

Miller and Thelen (1986) found that most clients anticipate that everything disclosed in a psychotherapy relationship will be kept completely confidential. As has been discussed, Maryland law specifies a number of circumstances when confidentiality must be breached. Both the failure to make such disclosures when required and the failure to ensure that our patients know of these requirements in advance should be avoided. Additionally, one should obtain a written authorization from the holder of privilege before any other information from treatment is released. Finally, as Pope (1990) recommends, only the specific information required to be released or the specific information requested be released should be disclosed. Disclosing beyond this should be avoided. Know the law, know what you are required to report, clarify in advance what you will disclose, and disclose only that. Our offices should be set up so that inadvertent disclosures are prevented. Care should be exercised in office design and soundproofing, the training of our staff to preserve each patient’s privacy, record storage and retention, and in the use of technology such as fax machines, computers, and the internet.

Supervision

If supervising a trainee or Psychology Associate we must be aware that we are fully responsible for all their actions professionally. We must ensure we assess supervisees’ training needs, supervise them closely, provide regular feedback and remediation, and ensure they are knowledgeable of, and follow, relevant State law and the APA Ethics Code. We may also receive supervision when confronted with difficult cases, when we are approaching the boundaries of our competence, and when we are working in new areas professionally, seeking supervision from experienced colleagues is a must. We should also document all supervision provided and received to make the process more effective as well as to provide the tangible record of what transpired.

Consultation

Like with supervision, consultation with an experienced colleague will assist us to provide patients with the best possible care. It also demonstrates that we recognize the limits of our competence and that our efforts are focused on providing patients with the best possible care. When confronted with a legal, ethical, or clinical dilemma, consultation is an important step. For legal issues, consult with an attorney. APA’s ethics office is available by telephone at (202)-336-5500 and by e-mail at ethics@apa.org for consultation on ethics issues. For clinical issues, consult with an experienced colleague. Also, listservs such as Division 42’s and the MENTORS listserv, may be great resources for members that provide easily access to a wide range of colleagues for consultation. Documenting all consultations and how we utilize the information provided will serve an important risk management function as well.

Boundary Issues and Multiple Relationships

This is an area of great importance both because of clinical and risk management concerns. Some may view a safe approach to be the avoidance of all boundary crossings and multiple relationships. But, we know this is not possible. There are times when the boundaries of touch, self-disclosure, time, and location of treatment may be crossed. There are times when multiple relationships will be engaged in. The APA Ethics Code highlights this in Standard 1.17, Multiple Relationships, which acknowledges that in certain settings, such as the rural environment, multiple relationships will be unavoidable. What should be kept in mind with boundary crossings and multiple relationships are prevailing community and professional standards, the patient’s best interest, consistency with your written treatment plan, and consistency with your theoretical orientation. But, we must always be careful about whose needs are being met and be sure that all actions are clearly in the patient’s best interest. Any action that will likely impair our objectivity and judgement or lead to exploitation or harm of a patient should be avoided. Since others will be judging this if a complaint arises, the use of consultation and adherence to professional standards are of great importance.

Termination and Abandonment

Psychologists know that we must never abandon patients. While we may appropriately terminate treatment when all treatment goals have been reached, there are other times when treatment may be ended; when a patient is not cooperative with treatment efforts, when a patient drops out of treatment, when a patient can no longer pay for services, and when managed care authorization is denied. However, it is important that we never abandon patients. Treatment should not be ended when patients are in crisis, regardless of the reason. If treatment is terminated and ongoing treatment needs exist, we must provide suitable referrals and offer to assist them with the referral process. Whenever treatment is terminated it is best to follow-up with a termination letter that clarifies the reason for the termination and makes any necessary recommendations. Both between appointments and during periods of absence we must be accessible to patients or make other appropriate arrangements for coverage in our absence. Patients should be informed in advance of how to contact us should a crisis arise and who to contact during periods of absence. Psychologists should also be aware of the circumstances when we must terminate a patient’s treatment. These include when a patient is not benefiting from treatment, when a harmful multiple relationship develops or is discovered, or when impaired competence develops or is discovered. In these situations it is best to terminate both verbally and in writing and provide referrals if ongoing treatment is needed.

References

American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. The American Psychologist, 47, 1597-1611.

Miller, D.J. & thelen, M.H. (1986). Knowledge and beliefs about confidentiality in psychotherapy. Professional Psychology: Research and Practice, 17, 15-19.

Pope, K.S. (1990). A practitioner’s guide to confidentiality and privilege: 20 legal, ethical, and clinical pitfalls. The Independent Practitioner, 10, 40-44.