Professional Ethics: Facing some new challengesApril 5, 2012

Presented by: Gary R. Schoener, M.Eq., Licensed Psychologist Director of Consultation & Training

CONSULTATION & TRAINING INSTITUTE

Ethical Framework

• Beneficence – doing good; helping• Non-maleficence – avoiding harm• Autonomy – client’s input and role• Fidelity – consistent with what promised• Justice -- welfare of client vs. others (e.g.

duty to warn); equitable use of resources – having a basis to proportion them

Ethical Decision-Making

• It is often not what is ethical vs. unethical, but the comparative ethicality of the options• This involves weighing which principles are

best dealt with through one option or another•What are the likely positive vs. negative

outcomes of choosing a given course of action?

 

Positive Outcomes Negative Outcomes

 Option A ______________ _________________  ______________ _________________  ______________ _________________ Option B ______________ _________________

______________ _________________ ______________ _________________

  

Decision table or chart

Electronic records• As of 23 January 2012 US major healthcare information

privacy breaches are 19 million records in 385 major HIPAA - reported incidents (each affecting 500 or more) since Sept. 2009 (2 ¼ years)• Minn. Attorney General Lori Swanson has announced a

lawsuit against Accretive Health Inc., a debt collection agency, or its role in a breach impacting 20,000 patients at North Memorial Health Care & Fairview Health Services. Data was on an un-encrypted laptop stolen from a parked rental car.• It is recommended that all devices be encrypted, even

those which are not supposed to be used to transport data, since people get careless

Challenges of private knowledge

• CASE 1: You have a case with severe abuse. You visit your sister and notice the family lives next door, and her kids are going over to play in the abuse house. What actions do you take if any? • CASE 2: Your brother brags to you how he

fooled child protection into closing a case, by threatening his wife and kids to deny the complaint. What action options are there? What if any should you take?

Traditional Boundaries with regard to Information Access

• Client has access to information about the professional based on published biography or revelations, news items

• Professional only has access to information about client from disclosures or access granted through signed releases

Variability between staff incommunity programs• Role – staff who are in the community with

client or who spend more time with client• Client expectations depending on role• Do you transport the client?• Recovery groups•Where do you live?• Other areas of social activity, politics

Realities of a small community

• You and client belong to same church, same social club, same athletic club• Client lives in same building as a friend of

yours – what are the issues?• Client interacts with a member of your family,

possibly without knowing the connection;• Former client interacts with you or a friend or

family

Traditional Concepts of Communication

• Communication by traditional mail (now called “snail mail”);• Communication by phone during limited business

hours; • Leave messages on answering machines for later

response;• Phone calls private, although a message left might

be saved;• Quick response not expected or promised

Communication in today’s world

• Expectation of being able to connect at all hours, even when professional is away from office, via cell phones, texting, etc.• Same is true for emails;• Emails and text messages create a record;• Emails can be misdirected or examined by

others – need to warn people about employer access to work computers

Challenges of Cell Phones & Hand-Held Devices • Do you have separate personal &

professional phones/blackberry’s, etc? it’s a challenge to have two, but a growing number of programs are providing them• Do you accept or receive calls? Is your

number blocked? Will your call be accepted if you are trying to contact client? Can client get your home #?

Text Messaging• A growing number of people do texting

instead of (or in addition to) emailing;• This is an abbreviated type of message

with less information;• This the only way to quickly reach people;• Unlike a phone call, it is silent, so people

can receive and view a text without the ring of a phone

Text Messaging (continued)

• Veterans Crisis Line (800) 273-8255 or text to 838255 http://veteranscrisisline.net • Crisis Connection has a program for

texting in 7 counties in northeast Minn. – they are receiving more texts from young people in a day than they previously received as phone calls in a month.

Smartphones & Tablets & Apps• The Therapist May See You Anytime,

Anywhere (NY Times, 2/13/12)• Cognitive bias modification (CBM) using

an app for social anxiety which directs attention away from hostile faces• Nader Amir at San Diego State – 30”/week

for anxiety disorder• Daniel Pine at NIMH – 40 children with

chronic anxiety

Smartphones & Tablets & Apps• European psychologists have tried a BMP

aimed at heavy drinking – people pushed away images of alcoholic drinks & zoom in on non-alcoholic ones – aids therapy• How to decide an recommending an app• How and when to ask client to use an app• Implications of doing this with an app that

the therapist designed or invented or sells

New Hazards • Client messaging about things during

session/activity – distracted? In group is there a breach of confidentiality?• Cell phones can film sessions – Staff

privacy rights?• 63% under 30 drove while using hand-held

phone; 30% texted • 5,500 people in US were killed in

distracted driving accidents in 2009

Social Networking Sites

• Facebook -- >500 million users• 92% of SNS users are on Facebook;• 50% log in on any given day; • Facebook – “friend” vs. “deferred”?• Posts from you, friend, relative, kid• 29% use MySpace; 18% Linkedin;• 50 million Twitter – 13% of SNS

Personal Exposure• CASE 3: Professional has gone through a

divorce – something his/her clients don’t know – they presume he/she is married• Some clients are working on issues of

relationship fidelity, etc.• Professional wants to sign up for a social

dating site, but is worried that a client will be asked about dating them•What options are there?

More visibility issues

• If you use a family photograph on Facebook, even with the highest privacy settings people see that photo;• Even if you don’t show your family to the

world, friends or family may show your photo or a family activity;• 90% of US physicians are on Facebook or

Linked in or some social media.

Hazards Never Imagined (for staff or even clients)• Happy slapping – assaulting someone while

others film it (usually on cell phone)• Sexting – sending racy photos of yourself or

someone else • Filming and/or broadcasting a party, or other

event• Live broadcast using cell phone or camera

(privacy invasion case – Tyler Clementi suicide at Rutgers – Dharun Ravi, age 19, convicted in Feb. 2012. Awaiting sentencing)

Hazards Never Imagined (cont.)• Fake profiles• Internet harassment – which can lead to

great distress the same as any type of bullying (1/3 to 1/2 of adolescents?);• Fake emails & chat screen names – so one

can harass secretly;•Massive Defriending – being shut-out by

groups of friends or classmates on a social networking site such as Facebook

Undressing your Friends (or enemies)

• FalseFlesh.com, billed as “adult image editing software” allows you to paste someone’s face onto a nude body• “Easily make any picture a

nude picture in minutes”

Cases to lose sleep over

• Draker v. Schreiber (2006, 2008) two students created My Space site with fake photos trashing Asst. Principal – Anna Draker sued them and their parents without success;•Megan Meier, driven to suicide by “Josh,”

created by the mother of a girl she was having a dispute with;

Cases (cont.)

• Ryan Hallingan, middle school student with a learning disorder was the focus of bullying & suggestions he was gay. He hanged himself after a girl who claimed to be his friend told him publicly he was a “loser” and that she had been pretending to be just like him so she could post their conversations on line and humiliate him.

Cases (cont.)

• Ghyslain Raza, the “Star Wars Kid,” a Canadian adolescent made a video in 2002 pretending to fight with a light saber as a school project. Another student posted it, adding music, and 900 million saw it on the web. Raza was taunted repeatedly and dropped out of school. After treatment for depression he got support, some from the internet, graduated law school, and heads a foundation for preservation.

Cases (cont.)

• Jesse Logan, Ohio teenager, sent nude pictures of herself to her boyfriend. After they broke up he sent them to other girls who circulated them on line. She was called a slut & ridiculed and started skipping school. Jesse went public with her story via a TV interview in May 2008, but two months later hanged herself. A classic example of the dangers of sexting.

Cases (cont.)

• 4/21/11 Buffalo, NY. Police invade home with assault rifles; throw man on floor; call him a “pervert” and “pedophile” and confiscate all computers and cell phones in the house including those of his wife and daughter. He did not have a passcode on his wireless router and it was utilized by someone nearby to download pornography. This can be done by neighbor, or from a car.

Other networking issues

• Caring Bridge – sites related to illness: therapist’s illness?; posting on client’s bridge?;• Blogs -- posting responses;• Sites focused on special interests: • Client alerts you to site• You encounter client on a site• Former client alerts you to site

Google & Net Research

• Should you “Google” a client?• Emergency Situation – identity issue;• Client denies suicide history but has prior

attempts;• Reality check on claims by client;• Checking on criminal justice history;• Screening for sex offenders

Google & Net Research (cont.)

•What if the client googles you? • Intern entering therapy googles her

therapist and then wonders if she’s “blown it” by doing this.• What if they tell you? What if you suspect?• Sites that evaluate professionals – YELP has

>25 million hits a month

Google & Net Research (cont.)

•What about hiring or credentialing process – do you google candidates?•What about interns or candidates for

supervision? • Do you disclose this practice?• If you stumble on information? • By 2010, 78% of US companies do internet

searches on applicants; 86% say it influences hiring decisions

Google & Net Research (cont.)• Clients may interact with each other, adding

complex dynamics to service delivery;• An angry client may create a website

attacking the counselor, or counseling, or the program or therapeutic approach;• “Googlegangers” – people with same name –

people can be mistaken about identity;• Anything on the internet could be false

Google & Net Research (cont.)• Facebook refuses to shut rape page run by

schoolboy (Sunday Telegraph,10/17/11)• Compromise of psychological tests:• www.mindfithypnosis.com/free-mmpi2-

online• www.hypnoticmp.3.com (Dr. Dobson)• Wikipedia entry on the Rorschach which

shows 10 blots and reveals common responses

More Internet Research Issues

• Clients & others may research medications, treatment methods, etc. on the internet. The impact varies with the accuracy of what they find.• Research has shown that searches about

medications produce different results in the US vs. Canada – Canadians are sent to Wikipedia & drug company sites first

Professional Ethics: Uncharted Territory • In certain circumstances there may be a good

reason to do a search of a client. Steve Behnke, APA Monitor, V ol. 41, #7, July 2010• Googling a patient is not necessarily unethical

– the key is that if you do it your actions should be in the patient’s best interest. Psychiatric News, Vol. 44, # 9, May 2009• Ethical analysis: Examine beneficence, non-

maleficence, autonomy, fidelity, & justice issues before doing it

AMA Policy: Professionalism in the use of social media • Refrain from posting patient information• Privacy settings; monitor internet presence• Appropriate boundaries with patient

interactions on internet• Separate personal & professional content

on line;• Confront or report unprofessional conduct

on line• Can undermine reputation & public trust

Some thoughts

• The internet creates a “small town” or ethnic subgroup for all of us;•With some areas of work such as criminal

justice, there may be greater challenges – clientele, role of security;• Health care rating sites are likely to grow

and include more therapists – healthgrades.com, vitals.com

The Battleground• Section 230 of the Communications

Decency Act: internet service providers have no accountability for anon. posts;• This area of law is evolving – some suggest

having contract with client;• Firms and approaches are evolving for self-

defense www.medicaljustice.com• Integrity Defenders works at burying

negative information w/ positive info.

The Battle Over Criticismon the Web• Second year law student Rockstar05

founded blog Thomas M. Cooley Law School Scam• School sought identity of Rockstar05 to

sue for defamation – issue is privacy rights of internet commentators vs. plaintiffs• This case was complicated because

company that hosts blog slipped up and revealed his email address

Self protection• Be aware of your web-presence • “Google” yourself• If there is false information, contact site

administrator to get things changed• Should you control on-line presence by

expanding it? Should you post your own www.google/com/profile?• Collegial discussion – develop standards

On line reviews• It’s hard to know what they mean – they

are not systematic;• The data about your work or practice may

be in error or outdates;•Many times there are only a few who do a

review so there can be a heavy influence of just a few ratings• Consumers focus on manner – civility,

perceived warmth, etc.

Accountability vs. Defamation• David McKee, Duluth, MN, neurologist

sued the son of a former patient for defamation for statements made on websites alleging bad bedside manner in the treatment of his father.• Dr. McKee was called a “real tool” and

alleged a callous attitude. This is not the only such case. It was dismissed although the Minnesota Supreme Court is currently hearing it.

Consent and Disclosure•What ground rules will you have for a

given unit, program, or practice as far as googling?• If you do “Google” someone, will you

disclose this to them?•What rules if any will you ask clients to

follow as regards the internet?• Will you ask them to maintain any privacy

or respect any boundaries?

Communications & Social Media Policy• Email: Email only to arrange or modify

appointments. Do not email content or important things we should discuss face to face…..• Rating or review sites: Info. on them is

questionable; I cannot respond to them and do not need positive ratings; ask me about any concerns you have about my services.

Communications & Social Media Policy (continued)• Text messaging: please do not use to

contact me – leave phone message for time changes, etc.; email not as good but at …. • Internet interaction: do not use wall

postings or other means of communication on the internet – none are private• Blog or Twitter: I do not follow you on

either – if there are things you want to share, bring them to a session

Communications & Social Media Policy (continued)• Friending: It is my practice to not accept

contact or “friend” requests from clients on social networking sites such as Facebook or Linkedin. They can compromise privacy and also complicate our helping relationship.•Website or Facebook Page: If you have

questions, bring them in a session. Please don’t interact on the internet.

Communications & Social Media Policy (continued)• Search Engines: I do not research my

clients on Google or other search engines. There may be occasions where you will direct me to look up something related to your life or experience, and if so we can discuss it at a future meeting. If you choose to check me out on the web I would note that not all information is accurate, and would suggest that we discuss anything which you find troubling.

Communications & Social Media Policy (continued)• Recording: Unless we have specifically

discussed it, there will be no recording of our meetings or any phone conversation. All of our discussions are private.• Records: I will maintain the records of our

work together as confidential although some billing-related information may be communicated securely. Please remember that any notes you make can compromise your privacy if not carefully protected.

Challenges for Licensure Boards

• Internet services -- How will these new areas of knowledge and skills be assessed for licensing purposes?• Will Boards in any way regulate the

creation of internet – based services? • In New Zealand there is an elaborate

website to combat depression in young people: http://www.thelowdown.co.nz

Helping Clients or Staff who are Victims of Cyber bullying• Clarify what victim wants/needs• Reinforce that they are not at fault• Avoid victim-blaming by saying things like

“you just need to be assertive”• Assist them in taking any action• Help with any underlying problems• Assist in improving healthy relationships

Gary R. Schoener, Licensed Psychologist, M.Eq.Director of Consultation and Training

2421 Chicago Avenue SouthMinneapolis, MN 55404

(612) 870-0565 Ext. 107grschoener@walkin.org

www.WalkIn.org

CONSULTATION & TRAINING INSTITUTE