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Risk Management vs. Standard of Care

This grotesque metastasis of risk management actually emerges from fatal confusions among risk management, psychoanalytic guidelines, and standard of care. Psychotherapists tend to conflate good, ethical, legal therapy with risk-free therapy, which protects practitioners, not clients. Again, there's nothing wrong with attending to professional risks and hazards for our own protection. That's why therapists should keep good records, establish well-articulated treatment plans, and consult clinical, ethical, and legal experts when in doubt. But watching out, primarily, for our own skins isn't the same as fulfilling our obligations to our clients.

What are those obligations? The standard of care that guides psychotherapists is a fluid mix of law, licensing regulations, ethical codes, professional consensus, community norms, and the like. We're required by law, ethics, and good clinical practice not to harm or exploit clients (which includes sexual and financial exploitation), to treat them with respect and dignity, and to protect their privacy and autonomy. We're legally and ethically bound to minimize the risk that mentally ill clients will hurt themselves or others.

The standard of care has traditionally not been driven by risk-management guidelines, which have been geared almost exclusively to reduce the risk of malpractice for therapists so insurance companies can reduce their financial liabilities. Standard of care has never required perfection; it's a minimum standard, based on the average practitioner, someone who achieves what's been called a "C-student standard." Careless mistakes or errors of judgment don't put you below the standard of care; nor does the standard adhere to psychoanalytic or any other particular theoretical orientation: rather, it's guided by a consensus among the practitioners of a particular method or clinical practice—group therapy, humanistic, feminist, family, cognitive-behavioral, whatever. Standard of care isn't determined by outcome: a therapist isn't guilty of substandard care because a client commits suicide, as long as the therapist has engaged in a coherent and documented process of legal, ethical, and clinically appropriate treatment. Nor does standard of care exclude what risk managers consider high-risk behaviors: giving gifts, self-disclosure, and boundary crossings (but not boundary violations, like unwanted or sexualized touch) appear rarely, if at all, in ethics codes or state laws, and yet the standard of care has been infiltrated by risk-management principles that, when carried to extreme, can undermine good practice.

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stephen144  - Appreciative of clear thinking   |Registered |2011-02-25 13:19:06
I appreciated this article and your presentation on Digital Ethics. You made a
convincing argument and a clear distinction between standard of care and risk
management... very useful.

Thank you.
ivkennedy  - LCSW   |Registered |2011-02-24 10:22:07
Dr. Zur, Your presentation on digital ethics has been so helpful. The
information is good. Your emphasis on the importance of therapeutic competence
rather than fear and risk management offers more possibilities for solutions to
these dilemmas. Your ideas are refreshing and show you are a curious and
creative clinician. Thank you.
ggro@comcast.net  - The ethical eye   |Registered |2011-02-24 09:08:15
This is the clearest article on ethics that I've ever read. It is a much needed
rebuttal to the fear mongering that is so prevalent today. My thanks to the
author for both his learned and common sense thinking.
snordquist  - Thanks for clarity   |Registered |2011-01-23 00:22:30
For a new PsychoSocial Rehabilitation Practicianer working with children and
adolescents, I found freedom and wisdom in learning the ethical boundaries,
learning the importance of good records, and consulting with trusted colleagues
for advice. I'll be reading more of your articles at your website.
mitelpunkt   |2011-01-05 20:58:11
I don't remember who said that "there are patients that we build a set to
treat them, and patients that we treat them to build a set".
The most
impressive change in a psychotic patient acurred once that a made an "acting
out" inviting him to a drink. After this event, very significant in
repairing his (and mine) relation with his father, he never again felt inot
psychotic states!!!
I was then affraid of bringing it to supervision, I never
did it, but it was a truely therapeutic act.

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