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Confusing risk management with a highly ethical and clinically sound standard of care ultimately undermines the latter and does a poor job of protecting the therapist. So, what's a therapist to do who wants to practice good therapy, but not end up on the wrong side of a trial or disciplinary hearing? First, we need to arm ourselves by learning about psychotherapy-outcome research, particularly as it applies to our own methods. Often licensing boards, investigators, and attorneys have little clinical understanding. Second, it should be obvious that we must be knowledgeable about the codes of ethics and state laws that apply to our field—psychology, social work, or counseling. And unlike the advice from the risk-management types cited above, we shouldn't be afraid to consult colleagues and appropriate experts whenever we're uncertain about something, and keep a record of the consultation.

This brings us to probably the most important single preemptive defense against getting into trouble: keeping good records. Generally, licensing boards decide whether clinicians have operated within the standard of care not by interviewing them personally, but by sifting through their records. In civil law suits and administrative hearings, it's often the client's word against the clinical records. Not only should clinicians keep good records on diagnosis or presenting problem, assessment, and mental status, but they should also keep notes on relevant biographical background information, treatment planning, crisis interventions, special phone calls, emergencies, and so on. It's particularly important to keep records of boundary crossings, dual relationships, and complex clinical, legal, and ethical issues. Make a note of anything you do that might be defined as a boundary crossing—giving or receiving gifts, extensive touch, exchanging therapy for barter, meeting a client outside the office, seeing somebody in therapy that you know in another context—and explain why you did it. What were the benefits to the client? What might have been the risk had you not accepted that gift? Would therapy have come to a screeching halt if you hadn't taken therapy out of the office? It may be helpful to remember that therapists most often get into trouble not because they did the wrong thing, but because they didn't follow (or didn't document) the right decision-making process.

Life, as every therapist knows, is often messy. Therapy can be messy, too; every day, we run into complex and ambiguous situations not covered in psychology books, much less by the professional guidelines of our profession. Lawyers and insurance functionaries are often paid to simplify life's complexities, control everything that happens, and make the messes disappear. But that isn't our job. We're here to help our clients accept, deal with, and perhaps do something creative with the messes life inevitably hands them.

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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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