Ethics
Ethics
Ethics
Clinical, Legal, and Ethical • Risk Management Consultant for The Trust
Considerations
Amanda D. Zelechoski, JD, PhD, ABPP
Valparaiso University
The Trust
www.psychlawtrauma.com
@azelechoski
Professional Ethics
• Clinical & Counseling Psychologists (APA Ethical Principles of
Psychologists and Code of Conduct)
• School Psychologists (NASP Principles for Professional Ethics)
• Counselors (ACA Code of Ethics) The ProQOL
• Clinical Social Workers (CSWA Code of Ethics; NASW Code of
Ethics)
• Marriage & Family Therapists (AAMFT Code of Ethics) Professional Quality of Life Scale
• Substance Abuse Counselors (NAADAC/NCC AP Code of Ethics) https://proqol.org/
• Physicians (AMA Code of Medical Ethics)
• Nurses (ANA Code of Ethics for Nurses)
https://www.npr.org/sections/health-shots/2018/11/09/666143092/should-childhood-
trauma-be-treated-as-a-public-health-crisis
Complex Complex
Exposure to chronic trauma,
Traumatic MH
usually within the caregiving Acute Chronic Complex Stress Symptoms Diagnosis
system, which can interfered
with the child’s ability to form a
secure attachment and sense of
safety and stability.
https://www.samhsa.gov/sites/default/files/programs_campaigns/nctsi/nctsi-infographic-full.pdf
Situations that can be traumatic for kids: Other Sources of Ongoing Stress
• Witnessing or experiencing • Life-threatening illness of a • Children frequently face other sources of ongoing
community violence caregiver stress that can challenge child welfare and mental
• e.g., drive-by shooting, robbery,
school fighting
health professionals’ ability to intervene.
• Witnessing domestic violence
• Witnessing police activity or • Some of these sources of stress include:
seeing a loved one arrested or • Car accidents or other serious
incarcerated accidents • Poverty
NCTSN, 2008
Relational Development
“The way we
The Impact talk to our
of Childhood
Trauma children
becomes their
inner voice.“
–Peggy O’Mara
Foster Child
The Impact
of Childhood
Trauma
https://www.echotraining.org/
What helps the traumatized individual Key Triggers for Traumatized Individuals
survive?
• Lack of power or control
• Assumption of danger
• Unexpected change
• Rapid mobilization in the face of perceived threat
Before we go Before we go
any further, any further, Who has custody of Jessica?
what what
What types of behavior is
potential potential Jessica engaging in?
issues and issues and
questions questions How long has this been going
on?
might you should you
What might have changed in her
have in have in life recently to trigger these
mind? mind? issues?
Case 1: Case 1:
Jessica Jessica
More info:
• Parents are separated and
You are contacted by Ms. currently have joint legal
Jones, who was referred to custody.
you by her child’s • Ms. Jones is seeking a TRO
pediatrician. During the against Mr. Jones, based on
intake appointment, you domestic violence allegations.
learn that Ms. Jones is • Jessica was recently
concerned about her 14- suspended from school for
year-old daughter, Jessica, smoking in the bathroom.
and her recent behavior at • Jessica does NOT want to be in
school and at home. therapy, but has been
compliant thus far.
• Ethical? • Legal?
• Confidentiality
• Mandated reporting
• Access to records
• Parents
• School
• Medical providers
• Courts
• Ethical?
• Confidentiality
• Clinician’s personal risk threshold
Working with
Traumatized Adults
Godbold, 2018
Benjet C, et al. The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health
Brown, 2013 Survey Consortium. Psychological Medicine. 2016; 46(2): 327—343.
Confidentiality Clarifications
• Privacy
• Who is client? • Legal right
• Mandated vs. voluntary treatment • Applies to the person
• Clients vs collaterals
• Case example • Confidentiality
• Ethical obligation
• Applies to the data/information
• Communicating with others Manny asks you if his • An extension of privacy
• Family girlfriend can attend
• Providers some of the sessions so • Privilege
• Employers that you can help them • Privileged communication is information that is disclosed in
• Others? work through some of the context of a specific relationship (e.g., psychotherapist-
their conflict. client) and cannot simply be demanded by a third party for
legal purposes
What should you do? © The Trust 2018
Legal Involvement
Managing Relationships
Potential Situations: Potential Roles: • Informed Consent
• Child custody • Letter of • Boundaries
• Employment-related Support/Advocacy • Be clear about the rules and expectations
issues • Written request for • Immediately address boundary crossings and
• e.g.,has
worker’s records unacceptable conduct
Manny asked comp,
you to
wrongful
write termination,
a letter to his
Manny
• Whatand his girlfriend
about treatment • Avoid multiple relationships
harassment havesummaries?
spit up and are now
• Repair ruptures
probation officer and
• Disability • in a bitter custody
Subpoena battle.
for records
judge advocating for him • Termination
You receive a subpoena
• Malpractice
and confirmingsuits
that he is • Deposition testimony
for his records from his
“cured” of his anger • Consultation
• Criminal adjudication • Court testimony
ex-girlfriend’s attorney.
• Documentation
issues.
What should you do?
What should you do?
Younggren, 2013
http://www.rememberingtrauma.org/
• To feel in control
OVC, 2001
Additional Resources
• The rise of EHRs have made records more accessible and • Consider what level of detail is needed in both written
searchable documentation and when consulting with other professionals.
• Pros: eases care coordination and communication across disciplines
Cons: frequent misunderstandings about who will be accessing records
• Information that is not pertinent to decision-making is not
• Some ways to deal with these concerns: necessary to share with the entire team
• Audit system that records who access records and when • despite the potential for psychological voyeurism, which is not
• Firewall that keeps MH notes separate from rest of chart. uncommon in medical settings
• Warnings that are triggered when someone tries to access a MH note
without authorization (Note: HIPAA prohibits this).
• Always assume the patient will be reading your notes and write them • Balance ethical obligations to cooperate with other
accordingly
• Use behavioral terms and quotes
professionals and protect the client’s confidential information
• Avoid subjective or judgmental comments • Be mindful of multidisciplinary power dynamics that may unduly
• Minimize the inclusion of unnecessary or irrelevant sensitive information influence judgment and compromise the patient’s dignity
Ashton & Sullivan, 2018 Ashton & Sullivan, 2018
Toward a
• Become familiar with the similarities and differences between
the various disciplines’ ethics codes to help guide Trauma-Competent
conversations and policy-making Integrated System
• Consult interprofessional competence literature
We can do better…
Trauma-Informed Care Integration and Trauma-Competence
1. Realize the widespread prevalence of trauma • Build meaningful partnerships that create mutuality
2. Recognize the signs and symptoms of trauma in among children, families, caregivers, and
clients, families, staff, and others professionals at an individual and organizational
level
3. Respond by integrating knowledge into policies,
procedures, and practices
• Address the intersections of trauma with culture,
4. Actively resist retraumatization of clients, history, race, gender, location, and language,
families, staff, and others acknowledge the compounding impact of structural
inequity, and be responsive to the unique needs of
diverse communities.
• https://www.integration.samhsa.gov/clinical-
practice/trauma-informed
• https://www.chcs.org/project/advancing-trauma-
informed-care/
Leahy (2018); Siegfried et al. (2016); Meltzer et al. (2013)
Self-Care
Blaustein, 2010; Saakvitne, Gamble, Pearlman, & Lev: Risking Connection Norcross & Guy, 2013
• Competence
• Impairment
• Vulnerability
• Judgment
nts
See clie
ork
Paperw g
ff m eetin
Sta ision
Superv
E
-CAR
SELF
https://dsps.wi.gov/Pages/SelfService/ProfessionalAssistanceProcedure.aspx
Godbold, 2018
Thank
Aman
da D.
Z ele c
h o ski
you!!
aman
da.ze
le cho
ski@ v
www alp o.e
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@ aze
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