Ethics and Confidentiality for Psychologists in Academic Health Centers

Psychologists in academic health centers (AHC) face important ethical issues including confidentiality when working with a multidisciplinary team, sharing of information through the electronic health record, obtaining informed consent in a fast-paced healthcare environment, cultural competency in the medical setting, and issues related to supervision and training. The goal of this paper is to describe ethical issues for psychologists in AHCs in the context of case examples, and to consider ethical decision-making tools to enhance clinical care. Considerations for best practices in integrated care settings will be discussed, and the APA Ethical Standards will be referenced throughout.     

Interprofessional Education: Preparing Psychologists for Success in Integrated Primary Care

Rapidly occurring changes in the healthcare arena mean time is of the essence for psychology to formalize a strategic plan for training in primary care settings. The current article articulates factors affecting models of integrated care in Academic Health Centers (AHCs) and describes ways to identify and utilize resources at AHCs to develop interprofessional educational and clinical integrated care opportunities. The paper asserts that interprofessional educational experiences between psychology and other healthcare providers are vital to insure professionals value one another’s disciplines in health care reform endeavors, most notably the patient-centered initiatives. The paper highlights ways to create shared values and common goals between primary care providers and psychologists, which are needed for trainee internalization of integrated care precepts. A developmental perspective to training from pre-doctoral, internship and postdoctoral levels for psychologists in integrated care is described. Lastly, a call to action is given for the field to develop more opportunities for psychology trainees to receive education and training within practica, internships and postdoctoral fellowships in primary care settings to address the reality that most patients seek their mental health treatment in primary care settings.     

With crisis comes opportunity: Building ethical competencies in light of COVID-19

ABSTRACT

The emergence of the coronavirus disease 2019 (COVID-19) pandemic has wide-ranging implications for the field of professional psychology. As clinical practice has rapidly adapted to ensure continuity of care, doctoral students have encountered unique opportunities for ethics-related competency development across practicum training settings. This article discusses the relevant American Psychological Association (APA) Ethics Code standards and additional ethical considerations facing trainees as they navigate their foundational clinical experiences and develop as professional psychologists in light of a pandemic.     

Ethical Considerations for Psychologists Providing Treatment to Arab Americans

Given the recent increase in hate crimes against Arab Americans, there are growing concerns over the mental health needs of Arab Americans and a pressing need for psychologists’ competence in treating this group. Although there are several clinical guidelines for other health care professions, there remains a paucity of information on the ethical issues that may arise for psychologists treating this Arab Americans. This article briefly provides background information on Arab Americans, highlights elements of Arab culture that might influence psychological treatment, discusses ethical issues that might arise when psychologists provide services to Arab Americans, and provides recommendations to address these issues.     

A Pain to Practice: Attitudes of Medical Family Therapists Working With Patients With Opioid Use Disorder

ABSTRACT

The prevalence of patients with opioid misuse in medical settings continues to rise, and it is unknown how much exposure medical family therapists (MedFTs) have in treating this issue. This study explored the attitudes of MedFTs (n = 58) when working with patients struggling with opioid use disorder in clinical practice. Results revealed that 43% of MedFTs had a low comfort level in working with this population and preferred to make referrals to primary care providers. Given that opioid use disorder cases are rising in healthcare settings, emerging mental health professionals would benefit from additional training to effectively treat this population.     

The Primary Care Health System as a Core Resource in Response to Terrorism

Abstract

Living through a terrorist event or under threat of attack affects both mental and physical health. A nation's primary care system plays a critical role under such circumstances. This article reviews the American experience after September 11, 2001 and advocates for integration of mental and physical health services in primary care settings as a key counter-terrorism strategy. Americans put their trust in primary care providers. The nation's healthcare system must develop and implement a strategy that informs and supports primary care providers in meeting the mental health needs of a nation confronted by terrorism.     

Factors affecting behavioral health provider turnover in US Air Force primary care behavioral health services

Turnover and retention of integrated behavioral health practitioners in primary care is a significant challenge with limited empirical evidence to inform risk factors. This study used retrospective archival data from the Air Force Medical Service’s Behavioral Health Optimization Program on all civilian contractors hired from September 2012 to November 2014 to examine the potential influence of training background (e.g., social work v. psychology), size of healthcare facility, or the presence of on-site mentors. Turnover was evaluated across a large managed healthcare organization of 121 civilian contractors (psychologists and social workers) in 72 specific clinic settings. These sites varied considerably in regards to geographic location, population diversity, size of patient empanelment, rural, suburban, and urban settings and all provided care to active duty military, their civilian dependents and civilian retirees. Results found that 54% of all psychologists and social workers hired for these positions quit or were fired within 8 months of employment. Smaller medical facilities were found to have a more significant attrition rate compared to medium- and large-sized facilities; no other differences were noted. Findings provide initial insight into a potential critical period in the first year of a behavioral health consultants on-boarding, as well as unique considerations for consultants placed in smaller facilities who may be at elevated risk for attrition. These preliminary findings suggest targeted interventions for new integrated care programs as well as important avenues for future research.     

Balancing Confidentiality and Collaboration Within Multidisciplinary Health Care Teams

As multidisciplinary perspectives are increasingly integrated into the treatment of health problems, opportunities for clinical psychologists in medical settings are expanding. Although cross-discipline collaboration is at the core of multidisciplinary treatment models, psychologists must be particularly cautious about information sharing due to their profession??s ethical standards regarding patient confidentiality. Psychologists?? ethical obligations require them to achieve a delicate balance between contributing to the treatment team and protecting patient confidentiality. In the current review, relevant ethical standards and federal guidelines are applied to everyday practices of clinical psychologists in medical settings. Additionally, recommendations for individual psychologists, health care organizations, and graduate training programs are presented.     

Integrating Contextual Issues in Ethical Decision Making

Many issues in ethics arise in relation to the contexts in which psychologists work. However, most ethical decision-making models reproduce the way in which psychologists tend to approach ethics by focusing on ethical dilemmas and proposing a step-by-step response to deal with them. Although these models might be useful, their emphasis on reactive approaches and their lack of contextualization constitute significant limitations on their applicability. In this article, an approach to ethical decision making that highlights the importance of the context in developing proactive strategies to solve ethical issues is proposed. This approach is further explained through its application to medical and rural settings. The implications of these suggestions to the training in ethics are finally discussed.     

Ethical and Legal Considerations in the Training of Mental Health Professionals

Summary

A discussion is provided regarding ethical and legal considerations that relate to the training of mental health professionals. A training program which emphasizes a proactive approach to identifying and resolving potential ethical and legal problems, and their close connection with clinical issues is described, as are the responsibilities of supervisors and supervisees in such a program. For illustrative purposes, a training vignette and a clinical vignette conclude the article.     

“Ethical considerations in providing psychological services to unaccompanied immigrant children”

Over 50,000 youth, mostly between the ages of 13 and 17 years, migrated to the United States (US) without familial accompaniment in the fiscal year 2018. The tripartite process of pre-flight, flight, and resettlement exposes these unaccompanied immigrant children (UIC) to multiple, and often ongoing, traumatic events that can significantly and adversely impact their mental health into adulthood. However, the ethical considerations for psychologists working with this growing population, with limited exceptions, remain largely unaddressed. As more and more UIC flee their home countries due to violence, abuse, and economic instability only to experience further stressors during the processes of detainment, custodial placement, and acculturative adjustment in the US, there is an increasing need for psychological services; thus, the importance of preparation of mental health providers is increasingly significant. Psychologists must have the requisite skills and knowledge of the complex experiences of UIC, and of how these intersect with salient cultural, developmental, and systemic factors, as a means of providing competent and ethical mental health treatment. The present article highlights several ethical issues that arise when providing psychological services to UIC, with particular consideration paid to the embeddedness of UIC in various organizational entities with which psychologists will likely need to interface when working with this population. Implications and recommendations for practicing psychologists and training programs are discussed.     

Ethical,Legal, and Psychosocial Issues in Care of Transgender Adolescents

SUMMARY

Complete care for transgender adolescents must be considered in the context of a holistic approach that includes comprehensive primary care as well as cultural, economic, psychosocial, sexual, and spiritual influences on health. Not all transgender adolescents have gender dysphoria or wish to undergo sex reassignment. In this article we focus on general care of transgender adolescents by the non-specialist working in primary care, family services, schools, child welfare, mental health, and other community settings.     

Considerations for ethical practice in managed care

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making.     

Patient and Family Descriptions of Ethical Concerns

Abstract

Ethically challenging situations routinely arise in the course of illness and healthcare. However, very few studies have surveyed patients and family members about their experiences with ethically challenging situations. To address this gap in the literature, we surveyed patients and family members at three hospitals. We conducted a content analysis of their responses to open-ended questions about their most memorable experience with an ethical concern for them or their family member. Participants (N?=?196) described 219 unique ethical experiences that spanned many of the prevailing themes of bioethics, including the patient-physician relationship, end-of-life care, decision-making capacity, healthcare costs, and genetic testing. Participants focused on relational issues in the course of experiencing illness and receiving medical care and concerns regarding the patient-physician encounters. Many concerns arose outside of a healthcare setting. These data indicate areas for improvement for healthcare providers but some concerns may be better addressed outside of the traditional healthcare setting.     

Collaborative Communication Between Psychologists and Primary Care Providers

Psychologists frequently collaborate in the care of patients managed in primary care. Communication with a patient’s primary care team is important to ensure coordination and continuity of care. The communication is far from seamless. Although The Health Information Privacy and Portability Act (HIPPA) is designed to promote sharing of clinical information while protecting patient confidentiality, unique problems arise when mental health records are included. Mental health records are subject to different regulations to protect the patient’s confidentiality. Thus, what is communicated and how it will be accomplished are challenges. Further, psychologists and primary care providers often view documentation differently, resulting in different styles of documenting that may also impede coordinated care. Increasingly, health care systems are moving toward electronic medical records, creating greater opportunities for an integrated record. Improved communication through the record can keep other providers abreast of the mental health care being provided as well as suggestions they can use to reinforce the mental health care treatment plan.     

Psychotropic Medication Consultation in Schools

Abstract

Assessing, consulting, and intervening with students being treated with psychotropic medications is an increasingly common activity for school psychologists. This article reviews some of the literature providing evidence for the greater need for training in school psychopharmacology. A legal and ethical case study is presented that highlights the complexity of medication issues for school psychologists. Training programs are encouraged to examine current curricular requirements to insure that graduates are exposed to evidenced-based treatments including pharmacological approaches. It is vital that school psychologists examine their own competencies as they work to ethically and legally consult with families and physicians to improve adaptive functioning in school-aged populations.     

The professional identity of counselling psychologists in health care: a review and call for research

Despite (a) anecdotal evidence which suggests that it is possible to be a counselling psychologist in non-traditional settings, and (b) the potential integration of counselling psychology foci with the medical model, there has been some discussion about whether counselling psychologists who practice in health care settings might experience a change in their professional identity. Professional identity is defined here as a sense of connection to the values and emphases of counselling psychology. The retention of professional identity seems important for counselling psychologists in health care settings. This is considering that the application of counselling psychology principles has the potential to make their contributions unique among mental health professionals in the health care arena. Here, the authors describe the evolution of ‘counselling health psychology’ and address issues of professional identity. Limitations of existing literature are examined. Recommendations for future research are also made.     

The Challenge of Integrated Care for Mental Health: Leaving the 50 minute hour and Other Sacred Things

A growing body of research has demonstrated the effectiveness of integrating mental/behavioral healthcare with primary care in improving health outcomes. Despite this rich literature, such demonstration programs have proven difficult to maintain once research funding ends. Much of the discussion regarding maintenance of integrated care has been focused on lack of reimbursement. However, provider factors may be just as important, because integrated care systems require providers to adopt a very different role and operate very differently from traditional mental health practice. There is also great variability in definition and operationalization of integrated care. Provider concerns tend to focus on several factors, including a perceived loss of autonomy, discomfort with the hierarchical nature of medical care and primary care settings, and enduring beliefs about what constitutes “good” treatment. Providers may view integrated care models as delivering substandard care and passively or actively resist them. Dissemination of available data regarding effectiveness of these models is essential (e.g. timeliness of treatment, client satisfaction). Increasing exposure and training in these models, while maintaining the necessary training in traditional mental health care is a challenge for training at all levels, yet the challenge clearly opens new opportunities for psychology and psychiatry.