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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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