Ethical - Tennessee Association for Marriage and Family Therapy

Updates in Ethical Issues for MFT Practice
Linda Oxford, LCSW, LMFT
John F. Kennedy, Ph.D., LMFT, LPC-­‐‑MHSP, NCC
February 2013
Map
•  Part 1: Revisions to the AAMFT Code of Ethics
•  Part 2: Issues Involving High Risk
•  Part 3: How the AAMFT Ethics Complaint Process
Works
•  Part 4: Four Keys to Ethical Practice as a MFT
Part 1: Revisions to The AAMFT Code of Ethics
Timeline of the Revisions
•  2011 –Task Force appointed to review the Code and recommend revisions
o  December 2011 – AAMFT Board approved first version of Code revision.
o  December 2011 & January 2012 – AAMFT members asked to provide comments. •  March 2012 – AAMFT Board of Directors approved new version of Code.
•  July 1, 2012 – New AAMFT Code of Ethics went into effect.
Revisions to AAMFT Code of Ethics Effective July 1, 2012
•  Addition of Headings
o  Added to provide a quick reference point for each subprinciple of the Code.
o  More efficient and easier to read
Specific Revisions
Preamble
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Fourth paragraph of the Preamble was revised to enhance clarity ...
“Code is binding on all members of AAMFT” Preamble •  The AAMFT Code of Ethics is binding on members of AAMFT in all membership categories, all AAMFT Approved Supervisors and all applicants for membership or the Approved Supervisor designation. AAMFT members have an obligation to be familiar with the AAMFT Code of Ethics and its application to their professional services. Lack of awareness or misunderstanding of an ethical standard is not a defense to a charge of unethical conduct. Subprinciple 1.1
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Gender identity and relationship status have been included as bases upon which members do not discriminate. • 
Makes AAMFT Code consistent with the Codes of other professional organizations. Subprinciple 1.1
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Non-­‐‑Discrimination o  Marriage and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity or relationship status. Subprinciple 1.3
•  Revised to include language regarding the documentation of precautions taken when the risk of impairment or exploitation exists due to multiple roles. Subprinciple 1.3
•  Multiple Relationships
o  Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken. Subprinciple 1.4
•  Revised to prohibit sex with not only current clients, but also sex with clients’ spouses or partners of clients
•  Prohibits sex with individuals who are known to be close relatives, guardians or significant others of clients. Subprinciple 1.4
•  Sexual Intimacy with Current Clients and Others o Sexual intimacy with current clients, or their spouses or partners is prohibited. Engaging in sexual intimacy with individuals who are known to be close relatives, guardians or significant others of current clients is prohibited. Subprinciple 1.5
•  Revised to emphasize that after two years, AAMFT members should not engage in sexual intimacy with former clients, or their spouses or partners. If members do engage in sexual intimacy after the two year time period, they must demonstrate that no harm has occurred. Subprinciple 1.5
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Sexual Intimacy with Former Clients and Others. Sexual intimacy with former clients, [client’s] spouses or partners, or individuals who are known to be close relatives, guardians or significant others of clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. After the two years following the last professional contact or termination, in an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients, or their spouses or partners. If therapists engage in sexual intimacy with former clients, or their spouses or partners, more than two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client, or their spouse or partner. Subprinciple 1.14
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This is a new addition to the Code. Lists four guidelines that must be followed when considering online therapy. States that members must comply with all relevant laws regarding online therapy Subprinciple 1.14
•  BEFORE STARTING ELECTRONIC THERAPY...
•  (a) determine that electronic therapy is appropriate for clients, taking into account the clients’ intellectual, emotional, and physical needs; •  (b) inform clients of the potential risks and benefits associated with electronic therapy; •  (c) ensure the security of their communication medium; and •  (d) only commence electronic therapy after appropriate education, training, or supervised experience using the relevant technology. Subprinciple 1.14
1.14 Electronic Therapy
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Prior to commencing therapy services through electronic means (including but not limited to phone and Internet), marriage and family therapists ensure that they are compliant with all relevant laws for the delivery of such services. Additionally, marriage and family therapists must: (a) determine that electronic therapy is appropriate for clients, taking into account the clients’ intellectual, emotional, and physical needs; (b) inform clients of the potential risks and benefits associated with electronic therapy; (c) ensure the security of their communication medium; and (d) only commence electronic therapy after appropriate education, training, or supervised experience using the relevant technology. Subprinciple 2.5
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Revised to emphasize that preparations for practice changes should be made before those changes occur. •  2001 Code uses the term “subsequent” (very confusing) • 
Members are expected to follow applicable laws when dealing with client records in this context. Subprinciple 2.5
Preparation for Practice Changes o  In preparation for moving from the area, closing a practice, or death, marriage and family therapists arrange for the storage, transfer, or disposal of client records in conformance with applicable laws and in ways that maintain confidentiality and safeguard the welfare of clients. Subprinciple 2.7
•  This is a new addition to the Code. •  Puts members on notice that securing electronic data and communications is a legal and ethical obligation. •  Members must follow applicable laws when dealing with electronic information. Subprinciple 2.7
•  Protection of Electronic Information o When using electronic methods for communication, billing, recordkeeping, or other elements of client care, marriage and family therapists ensure that their electronic data storage and communications are privacy protected consistent with all applicable law. Subprinciple 3.6
•  Requires members to maintain clinical and financial records in accordance with applicable law. •  Failure to follow such laws may constitute an ethical violation. Subprinciple 3.6
•  Maintenance of Records
o Marriage and family therapists maintain accurate and adequate clinical and financial records in accordance with applicable law. Subprinciple 8.2
•  Revised to make it easier to enforce. •  The language deleted from Subprinciple 8.2 seemed beler suited for a guidebook. Subprinciple 8.2
•  Promotional Materials. o Marriage and family therapists ensure that advertisements and publications in any media (such as directories, announcements, business cards, newspapers, radio, television, Internet, and facsimiles) convey information that is necessary for the public to make an appropriate selection of professional services and consistent with applicable law. Subprinciple 8.5
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Revised to remove the reference to the US Department of Education. The inclusion of USDE in this context is inaccurate and irrelevant to international members. Subprinciple 8.5
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Educational Credentials o 
In representing their educational qualifications, marriage and family therapists list and claim as evidence only those earned degrees: • 
(a) from institutions accredited by regional accreditation sources [omiled is the phrase “recognized by the United States Department of Education”]; • 
(b) from institutions recognized by states or provinces that license or certify marriage and family therapists; or • 
(c) from equivalent foreign institutions. Part 2: Handling Ethical Issues Involving High Risk
Key Risk Areas for MFTs: Client rights
Informed consent
Confidentiality Multiple relationships/Dual roles
•  Conflicts of interest
•  Documentation
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General Responsibilities Regarding Client Rights
•  Provide adequate information about the treatment process & mutual responsibilities
•  Promote anti-­‐‑
discriminatory practice
•  Protect client confidentiality / privacy
General Responsibilities Regarding Client Rights •  Promote and support individual rights to dignity, respect, autonomy in decision-­‐‑making, and health & safety
•  Affirm individual’s personal beliefs & identity
•  Protect individuals from abuse / exploitation
•  Promote effective communication & therapeutic relationship
•  Provide competent and individualized care
Informed Consent Involves:
•  Capacity to consent;
•  Being adequately informed in understandable language, both verbally and in writing, about the treatment process, potential risks and benefits, and mutual responsibilities;
•  Voluntary nature of consent; and •  Appropriate documentation
Confidentiality Major challenges include:
•  Managing confidentiality among participants in therapy when the client system includes more than one person;
•  Managing confidentiality when clients or members of the client system lack the capacity to authorize release of confidential client information;
•  Obtaining appropriate authorization to release client information; and
•  Protecting electronic information.
Multiple Relationships/Dual Roles •  Conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation •  Sexual intimacy with clients or clients significant others
•  Existing relationship with students or supervisees •  Sexual intimacy with students or supervisees •  Separation of custody evaluation from therapy
Conflicts of Interest
•  Conflicts of Interest. Marriage and family therapists do not provide services that create a conflict of interest that may impair work performance or clinical judgment (Subprinciple 3.4). •  No Furthering of Own Interests. Marriage and family therapists do not use their professional relationships with clients to further their own interests (Subprinciple 1.7). Most Common Ethical Complaints Against MFTs
1.  Substantiation of Professional Misconduct (Subprinciple 3.15e)
2.  Multiple Relationships/Dual Roles (Subprinciple 1.3)
3.  Confidentiality (Subprinciple 2.2)
4.  Treating MFT providing opinion on custody, visitation or residence of minor (Subprinciple 3.14)
Most Common Ethical Complaints Against MFTs 5.  Public Statements or Testimony o  Subprinciple 3.13
6.  Tie between Subprinciples o  1.4 (sexual intimacy)
o  3.8 (harassment)
7.  Tie among Subprinciples o 
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1.5 (sexual intimacy)
1.10 (referrals)
3.2 (Knowledge of Regulatory Standards)
4.1 (exploitation)
7.4 (truthful representation of services)
Meeting Standards of Care
•  Substantive Standards of Care
o  Legal
o  Ethical
o  Professional/Agency
•  Procedural Standards of Care – best practice Steps in Meeting Procedural Standards of Care
•  Consultation with colleagues/supervisors
•  Review of AAMFT Code of Ethics and professional ethical standards
•  Review of relevant law (including rules of law & case law), regulations and policies
Steps in Meeting Procedural Standards of Care •  Review of relevant professional literature
•  Appropriate legal & ethical consultation
•  Documentation of decision-­‐‑making process & rationale for choosing specific course of action • 
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Members may consult with an AAMFT Ethics Case Manager by phone or e-­‐‑mail: o  ethics@aamft.org
o  703-­‐‑253-­‐‑0471
In addition to immediate phone and e-­‐‑mail consultation services, members may obtain a formal ethical opinion from the AAMFT Ethics Commilee.
Advisory opinions are only provided on prospective behavior, not current or past conduct.
A member may be charged with an ethical violation if he or she reports having taken action that violates the AAMFT Code of Ethics.
Advisory opinions are non-­‐‑binding in the event an ethics complaint is filed against the member in connection with the situation discussed.
The AAMFT is not required to provide an advisory opinion. Part 3: How The AAMFT Ethics Complaint Process Works
How an Ethics Complaint is Made
•  Anyone can file a complaint; however, it must:
o be in writing
o be signed o include address, telephone number and e-­‐‑
mail address.
•  Anonymous complaints are not recognized.
•  Legal designee will determine whether the person against whom the complaint was filed is a member or applicant for membership.
How an Ethics Complaint is Made •  The complaint is reviewed by the Ethics Commilee Chair, who will:
o  Review the complaint to determine whether the complaint has been filed with the State or other regulatory body
•  If so, the case is placed in abeyance until the State has made a determination. The member is notified that charges have been filed and is responsible to keep AAMFT abreast of the outcome.
•  If the member is charged by the State or another regulatory body, or convicted of a felony or misdemeanor, the Ethics Commilee will assume these actions are appropriate. •  If the State or other regulatory body disciplines the member, then the member is charged with a violation of Subprinciple 3.15(e). In addition to the charges made by such regulatory bodies, the AAMFT Ethics Commilee may also decide to add additional charges.
How The Commilee Responds
If the Chair determines that no complaint has been made to the state or other governing body, and the charges, if proven factual, represent a violation of the Code of Ethics:
o  A leler is sent to notify the member of the complaint and the specific charges:
o  The member has 30 days from receipt of notice to respond to the charges.
If no response is received,
o  The case is sent to the full Ethics Commilee for review. Failure to respond to the complaint notice may be viewed as an admission to the charges and the commilee may choose to terminate the member’s AAMFT membership. o  The Chair may also choose to extend the timeframe within which the member may respond.
o  If a member resigns from the association during the process the commilee will still complete its investigation and may publicize the proven violation.
If the response is received:
o  Ethics Commilee Chair may seek further information from any party o  Case is submiled to the full Ethics Commilee at the next commilee meeting
•  Information including the complaint leler to the member, the member’s response, all documentation and any court materials the member received.
How The Commilee Responds If No Response is received o  The case is sent to the full Ethics Commilee for review. Failure to respond to the complaint notice may be viewed as an admission to the charges and the commilee may choose to terminate the member’s AAMFT membership. o  The Chair may also choose to extend the timeframe within which the member may respond.
o  If a member resigns from the association during the process the commilee will still complete its investigation and may publicize the proven violation.
If the Response is received o  Ethics Commilee Chair may seek further information from any party o  Case is submiled to the full Ethics Commilee at the next commilee meeting
•  Information including the complaint leler to the member, the member’s response, all documentation and any court materials the member received.
Response to Substantiated Allegations of Misconduct
o The Ethics Commilee may decide by a vote:
•  to censure the member or terminate his/her AAMFT membership and publicize it, or •  to sanction the member in the form of rehabilitation, e.g.:
•  require education or therapy
•  require work under supervision
•  require performance of community service
•  suspend membership •  to bar the member from re-­‐‑admission to the association
How The Accused Member Participates in the Process
•  The member is asked to respond in writing to the complaint and the specific ethical violations alleged.
•  The member is a part of the process and given an opportunity to respond at all levels.
•  The member may consult with legal counsel at any time, but must personally be an active participant in the proceedings and personally respond to the charges at all levels of the process.
How The Accused Member Participates in the Process •  If the member does not request a hearing within 15 days of receiving the Ethics Commilee’s recommendations for action, the Ethics Commilee’s recommendation becomes the final determination of the maler
•  If the member requests a hearing by the Judicial Commilee, the Ethics Commilee prepares and presents the case against the member pursuant to the rules of the Judicial Commilee. Part 4: Four Keys to Ethical Practice in MFT
Four Keys to Ethical Practice in MFT
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Alend to Informed Consent & Confidentiality
Make Good Documentation a Priority
Be Proactive in Managing Expectable Risks Maintain Appropriate Boundaries and Healthy Therapeutic Relationships
Action One: Alend to Informed Consent & Confidentiality
•  Principle 1:2 of AAMFT Code highlights Informed Consent.
•  Principle 2 of AAMFT Ethics Code addresses Confidentiality.
•  Principle 1:6 Don’t just comply with the laws, let clients know the laws.
•  Principle 2:1 Inform clients of limits of confidentiality.
•  Principle 1:12 Obtain consent for taping, recording or observing prior to doing so.
•  Principle 1:14 Address risks & benefits of electronic therapy.
•  Principle 2:4 and 2:7 Protect client records & electronic information.
•  Principle 2:3 and 2.6 Protect client identity & confidentiality in non-­‐‑
clinical activities and consultations.
Action Two: Make Good Documentation a Priority
•  Principle 3.6 of AAMFT Code -­‐‑ Marriage and family therapists maintain accurate and adequate clinical and financial records. •  Be sure to document not only your treatment decisions and your actions in response to an ethical dilemma, but your decision-­‐‑making process and rationale for those decisions and actions. Action Three: Be Proactive in Managing Expectable Risks •  Alend to Therapist Self Care.
•  Do Self-­‐‑of-­‐‑the-­‐‑therapist work.
•  Don’t practice in isolation. •  Keep abreast of the literature.
•  Nurture your personal relationships.
•  Seek therapy and supervision as needed.
All of these activities create a context for either enhancing ethical practice or puling oneself at risk for unethical behavior. Action Four: Maintain Appropriate Boundaries and Healthy Therapeutic Relationships •  Ethics Codes aren’t just concerned with making sure that therapists don’t have sex with clients.
”Appropriate boundaries are more complicated than that...”
•  Therapeutic relationships are the primary curative factor in therapy, and the primary risk factor in allegations of misconduct. If a Complaint is Made Against You •  Be familiar with your rights and responsibilities in the investigation and determination process. •  Consult with your professional liability insurance provider.
•  Consult with an alorney.
•  Remember that the fact that a complaint has been filed does not mean that you are going to be found guilty.
•  If you practice a sound decision-­‐‑making process for reaching ethical decisions, it is unlikely that you will be found guilty of an ethical violation.
Questions?