Ethical Violations Assignment | College Homework Help

In 350 words min please respond to the following min 1 citation. Use the Internet and Library to search for a case involving a human service professional accused of ethical violations due to behaviors and risks inherent in the digital age. Focus your search on the United States. Please respond to the following: • Describe the case in detail and report the outcome. • Apply the risk management strategies you learned from your readings to the case. • Analyze how the strategies could be applied and speculate as to how the outcome may have been different had these techniques been utilized.

Nine Risk Management Lessons for Practitioners
Daniel O. Taube
The Trust, Rockville, Maryland and Alliant
International University
Joe Scroppo
The Trust, Rockville, Maryland and Donald and
Barbara Zucker School of Medicine
Amanda D. Zelechoski
The Trust, Rockville, Maryland, and
Valparaiso University
Risk management is an essential skill for professionals and is important throughout the
course of their careers. Effective risk management blends a utilitarian focus on the
potential costs and benefits of particular courses of action, with a solid foundation in
ethical principles. Awareness of particularly risk-laden circumstances and practical
strategies can promote safer and more effective practice. This article reviews nine
situations and their associated lessons, illustrated by case examples. These situations
emerged from our experience as risk management consultants who have listened to and
assisted many practitioners in addressing the challenges they face on a day-to-day basis.
The lessons include a focus on obtaining consent, setting boundaries, flexibility,
attention to clinician affect, differentiating the clinician’s own values and needs from
those of the client, awareness of the limits of competence, maintaining adequate legal
knowledge, keeping good records, and routine consultation. We highlight issues and
approaches to consider in these types of cases that minimize risks of adverse outcomes
and enhance good practice.
Clinical Impact Statement
This article reviews situations and lessons, illustrated by case examples, learned
from our risk management experience. We highlight issues and approaches to
consider in these types of cases that minimize risks of adverse outcomes and
enhance good practice.
Keywords: risk management, ethics, professional practice, psychotherapy
Mental health practitioners enter their chosen
profession to help others. This good intent notwithstanding,
client dissatisfaction, harm, licensing
complaints, lawsuits, and other potentially
negative outcomes are facts of professional life.
DeMers and Schaffer (2012), for example, described
common licensing board complaints
(which are the most frequent disciplinary processes
that clinicians encounter) as including sexual
improprieties, poor record keeping, boundary
violations, insufficient supervision, substandard
court testimony, and unprofessional or negligent
This article was published Online First October 4, 2018.
Daniel O. Taube, The Trust, Rockville, Maryland, and
Alliant International University; Joe Scroppo, The Trust,
Rockville, Maryland, and Donald and Barbara Zucker
School of Medicine; Amanda D. Zelechoski, The Trust,
Rockville, Maryland, and Department of Psychology, Valparaiso
University.
This article is not intended to be risk advice about a
specific situation, and is not a substitute for an actual
consultation. All authors are consultants for The Trust Risk
Management Service.
Correspondence concerning this article should be addressed
to Daniel O. Taube, 2282 Union Street, San Francisco,
CA 94123. E-mail: dtaube@alliant.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Practice Innovations
© 2018 American Psychological Association 2018, Vol. 3, No. 4, 271–283
2377-889X/18/$12.00 http://dx.doi.org/10.1037/pri0000078
271
conduct. Knapp, Younggren, VandeCreek, Harris,
and Martin (2013) reported overlapping but somewhat
different situations that can give rise to malpractice
lawsuits, such as treatment failure and
lack of consultation or referral, child custody disputes,
breaches of confidentiality, and client suicide.
As a result, it is necessary to consider methods
to help address these potential untoward
actions, omissions, and consequences. Risk
management (RM), one such method, refers to
an awareness of, and practices that focus on
identifying and mitigating, these potential negative
outcomes of professional practice (Knapp,
Handelsman, Gottlieb, & VandeCreek, 2013).
Put another way, it is “the prospective assessment
of a retrospective evaluation” (E. Harris,
personal communication, 2014). The key is
awareness of those situations, clients, and practitioner
factors that increase risk. Without such
awareness, it is less likely that clinicians will
implement potential strategies and actions
needed to mitigate these risks. This approach
has the purpose of protecting the clinician from
the potential pitfalls of engaging in professional
practice and, at the same time, promoting competent,
careful, and ethical practice. It is not,
however, a system of aspirational principles or
positive ethics (Handelsman, Knapp, & Gottlieb,
2002); rather, it is a pragmatic approach
that is intended to prevent or reduce the likelihood
of undesirable outcomes for the professional
and the client.
RM approaches, much like the original
American Psychological Association’s (APA’s)
ethics code (APA, 1953), developed from listening
to the difficulties that practitioners encountered
when grappling with the conflicts and
challenges of daily practice. Since its inception,
our RM consultation team has responded to
some 70,000 calls regarding these kinds of challenges
from professionals across the country,
with the current authors fielding some 20% of
those requests. The RM team is composed of
professionals who have training in law, and
clinical and forensic psychology, and substantial
experience in RM and forensic practice.
Based on that experience, we have oriented the
ensuing discussion toward raising some pragmatic,
relational, cognitive, and emotional aspects
of the struggles that professionals have
presented to the team. Note, however, that this
discussion is by no means intended to be an
exhaustive list of RM issues or strategies, nor is
it intended to provide a core set of ethical best
practices. Such comprehensive treatments of the
topic are beyond the scope of this article; thorough
explorations can be found elsewhere (see,
e.g., Knapp et al., 2013; Knapp, VandeCreek, &
Fingerhut, 2017; Koocher & Keith-Spiegel,
2016; Woody, 2013). Rather, in this article, we
focus on heightening awareness of common
problems we encounter and the advice we often
provide.
Engage in a Thorough Informed Consent
Process and Know Who the Client Is at
Every Moment
Informed consent reflects the ethical principle
of honoring the autonomy and moral agency
of persons (Beauchamp & Childress, 2012;
Koocher & Keith-Spiegel, 2016). Concomitantly,
it developed as a legal doctrine in the
context of medical malpractice case law (e.g.,
Kaimowitz v. Michigan Department of Mental
Health, 1973; Natanson v. Kline, 1960). This
doctrine posited three elements as essential to
the right of persons to make decisions about
their own care; specifically, consent must be
voluntary, competent, and informed (Cotsonas,
1991; Lidz et al., 1984). Though there has been
some variability regarding the nature of the
information required to fulfill this duty, cases
and ethics codes have generally required a description
of the proposed treatment or assessment
procedure, its purpose, risks and benefits,
a description of alternatives and their potential
outcomes, as well as the potential outcomes of
not undergoing any procedure at all (Cotsonas,
1991).
From an RM perspective, informed consent
also serves a definite purpose: It helps to prospectively
resolve many difficult situations that
are likely to arise because of ambiguity about
important issues (e.g., who is the client?)—that
is, it minimizes surprises and forestalls misunderstandings.
Further, it is a baseline from
which expectations regarding the nature of the
interpersonal, financial, and professional relationship
are articulated and clarified, and where
the structure of the relationship is established.
Forgoing the consent process, or treating it as a
mere formality to be dispensed with, can undermine
the treatment relationship and result in
272 TAUBE, SCROPPO, AND ZELECHOSKI
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anger, confusion, and even a sense of betrayal
(Knapp et al., 2013).
For example, consider a clinician who accepted
an anxious and depressed 31-year-old
man into treatment. A good portion of this client’s
distress seemed to stem from the conflict
he experienced in his marriage. After 10 sessions,
the client requested that his wife join
them for some joint sessions. The professional
agreed that this might be helpful to the treatment,
and the client’s wife began meeting with
them. In the first session involving both the
client and his wife, the focus moved quickly
from his wife’s description of the client’s depression
and agitation to their intense conflicts
over intimacy and parenting. The clinician
shifted to addressing the couple’s distress. After
eight more sessions, the client found himself
frustrated with the lack of progress in the joint
meetings and asked to go back to individual
sessions with the clinician, who agreed to do so.
The client ultimately decided to divorce his
wife. Shortly thereafter, the couple commenced
a contentious custody dispute. His wife then
requested “her records” from the joint sessions
with the clinician. The clinician attempted to
explain to her that the sessions and the resulting
records (which were initially and currently focused
on her husband as the client), belonged to
the husband. When the clinician further explained
that she could not provide the records to
the wife without her soon-to-be ex-husband’s
authorization, the wife became angry and argumentative,
saying, “You never told me this was
his therapy, or that these were not my records; I
thought we were doing marital counseling.” She
threatened to complain to the licensing board.
In this circumstance, a third party—the client’s
wife—entered the treatment in a significant
way, and the focus of treatment shifted.
That created a number of issues, including the
need to define who the client was, how records
would be kept (e.g., they would include information
about both the client and his wife), who
would have access to those records, and the
degree to which the client’s wife could expect
confidentiality to be maintained. The clinician
could have avoided confusing and angering the
wife by engaging in a new informed consent
process upon her entrance into the treatment.
For example, she could have used The Trust
collateral contract (The Trust, n.d.-b) to establish
these parameters when the client’s wife first
agreed to attend sessions with her husband. Had
she done so, this misunderstanding could easily
have been avoided.
Maintain Good Boundaries and Set Limits
With Clients When Necessary, Even When
Doing So May Frustrate or Disappoint
As clinicians, helping others is a fundamental
part of professional, and often personal, identity.
Moreover, ethics codes (e.g., American
Counseling Association [ACA], 2014; APA,
2017) advise clinicians to practice “beneficence”
“to do good for others” and to avoid
unnecessarily harming clients. Mental health
professionals, however, must set and keep good
boundaries—actions that can lead the naïve
practitioner to mistakenly believe they are hurting
the client. Moreover, the failure to set and
keep good boundaries can mislead or confuse
the client. Boundaries, or what have been defined
as “multiple relationships” in some ethics
codes (cf. ACA, 2014, Section A.6; APA, 2017,
Standard 3.05), refer to activities that are outside
the typical role of a psychotherapist or
evaluator. They can be subtle or pronounced
and include the possibility that a practitioner
can have more than one relationship with a
client.
This concept grew from initial concerns
and prohibitions regarding sexual improprieties
by practitioners (Gottlieb & Younggren,
2009; Gutheil & Gabbard, 1993; Younggren
& Gottlieb, 2004) but evolved to include
many possible varieties of relationships.
Some behaviors and roles are clearly prohibited
and others are not. The former have been
described as boundary violations, and the latter,
boundary crossings (Gutheil & Gabbard,
1993). Boundary violations occur if the additional
role or activity would be expected to
compromise the professional’s “objectivity,
competence, or effectiveness in performing
his or her [professional] functions . . . or
otherwise risks exploitation or harm to the
person with whom the professional relationship
exists” (APA, 2017, Standard 3.05).
Some theorists have argued that boundary
crossings may have a significantly positive
impact on treatment outcomes and client experiences
(e.g., Pope & Keith-Spiegel, 2008;
Zur, 2007). Others point to the potentially
harmful effects that such crossings could have
NINE RISK MANAGEMENT LESSONS 273
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(Gutheil, 2005). The challenge, of course, is
prospectively determining what the outcome
will be.
For example, consider the following scenario:
A psychotherapist began to treat a demanding
and aggressive client who, despite
the testing of limits, also lavished praise on
the clinician and described him as the “best
therapist I’ve ever had” and a “life-saver.”
The client then began to make an increasingly
onerous and intrusive set of demands on the
clinician. At first, the client telephoned the
clinician multiple times per week during the
evenings and sometimes two or three times a
day. He then started sending frequent e-mails
demanding immediate responses, followed by
caustic, angry text messages when he did not
hear from the clinician as quickly as he desired.
The client then berated the clinician in
session because of these delays, though he
continued to periodically tell this professional
that he was the most important person in his
life. The clinician began to feel overwhelmed
and intruded upon, so in an attempt to manage
his distress, soothe his client and maintain the
alliance, he acceded to a number of these boundary
crossings (e.g., taking late-night phone calls;
moving other clients’ appointment times to accommodate
last-minute “crises” this client reported;
disclosing personal information in response
to this client’s demand that the therapeutic
process be “fair”).
Ultimately, the client’s demands and anger
escalated to the point at which he parked his
car at the professional’s office so that other
clients could not gain access to the entrance.
At this point, the practitioner had lost control
of the therapy and, having granted a series of
increasingly intrusive demands, ultimately
became “hostage” to having accepted those
earlier violations. When the clinician finally,
out of necessity, said “no,” and attempted to
set limits on the client and told him that he
could not intrude upon his practice and his
personal life in such a manner, the client
became verbally abusive in session, left
abruptly, and filed a board complaint. In this
situation, it is possible that the board might
determine that the practitioner had unwittingly
communicated acceptance of the client’s
problematic behaviors.
This example highlights the importance of
setting initial expectations in the professional
relationship. The informed consent process (as
noted in the earlier vignette) is an effective
means of doing so, as is discussion of, and
documentation clarifying, typical office policies.
Once set, sticking to these limits on client
requests and clinician responses to extrasession
communications, frequent contacts, or other
events that signal pressure to vary one’s role, is
prudent (Gutheil, 2005). Though there will be
exceptions, a thoughtful, reflective, and structured
decision-making approach is important
for reducing the risk of untoward outcomes
(Gottlieb & Younggren, 2009; Pope & Keith-
Spiegel, 2008), as is reaching out to colleagues
for their input and counsel when such events
begin to occur. Further, as we address in more
detail in the section on record keeping, careful
documentation regarding one’s reasoning for
departing from a structure or limit can afford
some additional protection. But the threshold
steps are the setting of initial expectations
through informed consent and clear office policies,
the recognition that these potentially problematic
behaviors are occurring, and addressing
them when they first begin. If that had occurred
in this example, at the least, the client and
clinician would have had a better chance of
negotiating a workable relationship, or the clinician
could have terminated and referred the
client to a program perhaps better suited to
address his needs.
Though Structure Is Important, Excessive
Rigidity Carries Its Own Risk
Structuring the relationship and maintaining
boundaries are important RM considerations,
but problems can also arise when practitioners
become too rigid with clients. This may happen
when, out of anxiety, habit, annoyance, or lack
of awareness, the clinician reflexively imposes a
boundary, primarily to reduce the clinician’s
distress about a situation. A number of theorists
have discussed some potential pitfalls of the
rigid application of ethical standards, limits, and
boundaries (Gottlieb & Younggren, 2009;
Knapp et al., 2013; Pope & Keith-Spiegel,
2008; Zur, 2007). These can include such effects
as needlessly distancing oneself from
one’s clients, limiting the clinician’s ability to
strengthen the alliance, undermining the treatment
plan, unnecessarily restricting the avail-
274 TAUBE, SCROPPO, AND ZELECHOSKI
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ability of services in small communities, and
stifling innovation.
Consider the following example: A clinician
has been treating a high-functioning client for
many years, and they have had a good therapeutic
alliance. The client was elderly and had
begun to suffer a serious decline in physical
health. After a few months of extensive medical
testing, the client reported that she had been
diagnosed with a terminal and painful cancer
and that, after having given it considerable
thought, she had decided to end her life. The
clinician’s immediate instinct was to psychiatrically
hospitalize the client and terminate the
case, even though it was unlikely that a psychiatric
hospitalization would have changed the
client’s decision. The clinician, however, decided
to reevaluate her initial response to the
situation and considered whether there were
ways to adopt a flexible approach that balanced
her own anxiety about her increasing proximity
to ethical/regulatory boundaries with the need
and desire to help the client at a critical time.
The clinician consulted with two experienced
colleagues and, at their suggestion, conducted a
comprehensive diagnostic assessment of the client
and obtained the client’s authorization to
speak to her oncologist. After doing so, the
clinician concluded that although the client was
moderately anxious and depressed, her desire to
die appeared to be mostly a rational response to
a realistic situation rather than the product of
any major mental illness. The clinician knew
that the client wanted and needed help as she
faced the final stage of her life, and the clinician
was loath to end the relationship, though she
knew that others might view her failure to actively
thwart the client’s planned suicide as an
ethical or RM lapse. The clinician decided to
establish some conditions under which she was
willing to continue the treatment. She informed
the client that she would do nothing to assist or
abet the client’s suicide plans and that she
would continue the treatment only if the client
was willing to bring her spouse to a session and
disclose to the spouse the client’s plans to end
her life. She also clarified that she might seek
external intervention if it became clear that the
client no longer retained the capacity to make
reasonable decisions.
In this scenario, the clinician engaged in selfreflection
following her strong initial reaction.
After seeking help in thinking through the situation
and careful consideration, she decided to
accept the higher risk associated with refraining
from reflexively psychiatrically hospitalizing a
suicidal client. Leaving aside whether this is the
“right” or “wrong” thing to do, the scenario
illustrates how, after thoughtful reflection of
ethical and RM principles, a clinician may
choose to continue to engage with a high-risk
client or situation, while documenting his or her
rationale for doing so, and implementing conditions
that seek to minimize the clinician’s risk
for ethical or RM lapses.
Be Attentive to One’s Feelings, Particularly
When These Involve Fear, Anger, or
Resentment of a Client
A professional’s immediate reactions and responses
to a difficult situation can be important
sources of information and guidance. But impulsive
reactivity can result in ill-guided, and
even destructive, decisions. Clinical work inherently
creates the likelihood that the clinician
will experience complicated feelings in relation
to the client and the process of treatment
(Knapp, Gottlieb, & Handelsman, 2017b; Rogerson,
Gottlieb, Handelsman, Knapp, & Younggren,
2011). This is often the case when dealing
with particularly high-risk clients, high-risk situations,
or both (Knapp et al., 2013). And a
growing body of research has demonstrated that
decision making is directly affected by particular
emotional states (Guzak, 2015; Kouchaki &
Desai, 2015; Winterich, Morales, & Mittal,
2015). As such, it is especially important for
clinicians to go slowly in such situations and to
carefully monitor their own reactions toward
clients and circumstances throughout the course
of the professional relationship. In particular,
good RM often involves pausing, noticing, and
reflecting whenever the professional feels impelled
to take quick action.
For example, a professional began seeing a
10-year-old child in individual therapy, after
being contacted by the child’s mother. This
request followed a recent custody dispute in
which therapy for the child was ordered by the
court. Over time, the mother became increasingly
inconsistent, cancelling appointments at
the last minute or just not showing up, as well as
expecting last-minute scheduling adjustments,
apparently in order to create barriers to the
father’s participation in therapy. She also be-
NINE RISK MANAGEMENT LESSONS 275
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came angry about the charges the psychotherapist
imposed for missed sessions, despite a clear
office policy to which she had agreed when
treatment had begun. In response, the clinician
became frustrated with the mother’s attempt to
manipulate the situation and informed her over
the phone that she thought it best to terminate
therapy immediately; the clinician also stated
and that she was going to inform the court of the
mother’s noncompliance with the court order.
The mother then threatened to file a licensing
board complaint against the professional and
immediately demanded copies of the child’s
records. The clinician refused to provide the
mother with the child’s records because she was
concerned that the mother was planning to use
them in the custody dispute, and perhaps even
against the clinician in a formal complaint. In
this situation, the professional responded impulsively
to her feelings of frustration with the
mother, abruptly terminated services to the
child, and threatened the mother with a report
to the court about the mother’s noncompliance.
There were, however, a number of other options
the clinician could have considered prior to
taking such rash actions. To have those options
available, though, the clinician first would need
to have been attentive to her affective experience
(Rogerson et al., 2011). In essence, had she
“taken [her] emotional temperature” (Knapp et
al., 2017b, p. 165) following the interactions
with this parent, it would have given her the
opportunity to slow her decision-making process
and allow for a more refined, reflective
consideration of the problem and its potential
solutions (Guzak, 2015; Rogerson et al., 2011;
Sobelman & Younggren, 2016). These solutions
might have included talking with the
mother about the clinician’s concerns and providing
clear notice that, unless certain contingencies
were met (i.e., showing up consistently
and on time or providing ample notice of the
need to cancel), the clinician would not be able
to continue working with the child. Even after
being clear about her expectations, the professional
might still need to terminate if the mother
could not, or was not willing to, meet them. In
that case, however, the clinician could have
tried to de-escalate the situation with both parents
as much as possible and to explain to them
that she believed the child might be better
served by another psychotherapist, given the
increasing conflict and apparent lack of fit. The
professional could also have offered to do several
termination or transition sessions and expressed
her willingness to help facilitate the
child’s transition to another clinician.
With respect to the records request, the professional
reacted from a concern for her client’s
welfare, mixed with fear of adverse action being
taken against her, and refused a request from a
parent who may well have been legally entitled
to those records. Had she included a policy
regarding records access in the informed consent
and parent agreement stage (see, e.g., The
Trust, n.d.-a), then she might have avoided the
problem by reminding the mother that she had
agreed to refrain from requesting or using records
in the custody dispute so as to ensure the
child’s therapy was a safe and confidential
place. If she did not have a specific parent
agreement in place, then the clinician—and the
parents—would have been better served if she
had expressed any concerns she might have had.
If pressed, she could have considered the nature
of her objections, sought assistance from a
knowledgeable colleague regarding her legal
and ethical duties, and determined whether she
had grounds to deny access. As this scenario
illustrates, attending to emotional responses
amid the complex vicissitudes of treatment is
not only important from a clinical perspective
but also can help to avoid the escalation of
problematic responses. It allows for better, more
deliberate decision making and can reduce the
potentially adverse impact of emotionally laden
responses.
Differentiate One’s Values, Feelings, and
Needs From Those of the Client
Situations can arise for practitioners in which
it is necessary to step back and assess whether
their own values and goals are consistent with
those articulated by the client (Knapp, Gottlieb,
& Handelsman, 2017a; Koocher & Keith-
Spiegel, 2016; Pope & Keith-Spiegel, 2008;
Tjeltveit & Gottlieb, 2010). This could involve
direct conflicts between the clinician’s personal
values or beliefs and the client’s presenting
issue (e.g., a client considering terminating her
pregnancy and a clinician whose religious beliefs
are strongly opposed to abortion) or situations
in which the clinician’s own feelings or
issues start to permeate the therapeutic relationship.
276 TAUBE, SCROPPO, AND ZELECHOSKI
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Consider the following example: A professional
began to work with a depressed adolescent
client and, at the onset of treatment, discussed
with both the client and the client’s
parents his desire to keep as much of the client’s
disclosures as confidential as possible in order
to develop the therapeutic relationship and help
the client feel comfortable opening up. The professional
explained the standard limits of confidentiality
to the client and parents, including
the professional’s duty to break confidentiality
if he believed the client was a danger to himself
or others. All parties were in agreement, but the
professional did not provide any specifics or
examples of instances in which he might consider
needing to disclose information to the
client’s parents without the client’s agreement.
Several months into therapy, the client disclosed
that he had begun cutting his arms and
experimenting with marijuana as a way to cope
with his depressive symptoms. The clinician
became anxious, immediately called the client’s
parents, and reported to them what the client
had disclosed. The client was very upset and
told the clinician that he was never telling him
anything again. The clinician felt terrible afterward
and wondered whether there was another
way he could have handled the situation. The
next week, he was surprised that the client
showed up for their scheduled session; the professional
spent a good portion of the session
apologizing to the client, despite the client’s
visible discomfort and repeated assurances that
he understood why it had to be done.
In this scenario, the clinician let his own
values, feelings, and needs get in the way of
doing what was in the best interests of the
client. Further, he was not clear about the level
of risky behavior he could tolerate in a client.
Had he been more aware of that threshold, he
may have provided better informed consent to
the client and the parents regarding what specific
types of information he would feel compelled
to disclose and under what circumstances.
This clarity would have involved
carefully assessing the types and severity of risk
behaviors the clinician felt equipped to manage
on his or her own versus his or her need to
involve a client’s family members to assist. In
this case, many clinicians would not have considered
the client’s behaviors to be particularly
high risk. Had the professional talked with the
client about his concerns for the client’s safety
and worked with the client clinically to help him
feel comfortable telling his parents about these
behaviors by himself (or with the support of the
professional), he might have avoided this rupture
in the alliance. In addition, when the client
surprisingly returned the following week, the
professional’s sense of distress and need to repair
the rupture resulted in his going overboard
in his efforts to assuage his own guilt rather than
being attentive to the client’s response to his
apology. Awareness of one’s own values and
reactions to distressing client behaviors and
complex relational issues is an important RM
strategy and requires regular monitoring of oneself
in response to tense or surprising clinical
situations.
Know the Nature and Limits of One’s
Professional Competence (and Role)
Professional competence has many facets. At
its broadest level, competence has intellectual
and emotional components (Koocher & Keith-
Spiegel, 2016). It further relates to the skills,
knowledge, and attitudes a professional has developed,
and consists of cultural, interpersonal,
decision-making/reasoning, professional, ethical,
intervention, supervision, and consultation
dimensions (Hunsley et al., 2016; Kaslow et al.,
2004; Rodolfa et al., 2005). From ethical and
RM perspectives, it is crucial to recognize when
one does not have adequate competence to perform
a given set of professional tasks or roles
(e.g., APA, 2017, Standard 2.01). Examples of
stepping outside one’s areas of competence can
include such activities as completing an assessment
on an adolescent but having no training or
experience with teens; being unable to track
what a client is saying in an intake because the
professional has had to use pain medication for
a recent oral surgery; or beginning treatment
with a person who is culturally and ethnically
different than the practitioner but about whose
culture and history the practitioner has little or
no knowledge.
Competence is also not a fixed state: It can
develop, become outdated, and wax and wane
depending on the clinician’s functioning, the
client, and the treatment situation. That is particularly
the case when there are forces—
internal, external, or both—that push the practitioner
to take an expansive view of his or her
professional capacities. Difficulty in launching
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or maintaining one’s independent practice, the
promise of lucrative opportunities in another
area of professional work in which the practitioner
does not have adequate knowledge or
experience, pressures by employers and organizations
to engage in activities in which the
practitioner is not trained, and a lack of recognition
that a particular situation or client requires
a distinct set of competencies are just a
few examples. Often, though, it is as simple as
an earnest desire to help, or the fear of angering
(and perhaps even losing) a client by refusing a
request, that allows clinicians to be pulled into
activities for which they are not adequately prepared
and that might create multiple roles or
conflicts of interest that expose them to considerable
risk.
Consider the following scenario: A clinician
has been providing individual therapy to an
adult male for several months, primarily focused
on posttraumatic stress symptoms following
a car accident. The client has made good
progress and, during a typical weekly session,
has asked the clinician to write a letter to the
court for his upcoming personal injury civil
hearing, in which he is suing the driver of the
other vehicle involved in the accident. The client
and his attorney would like the clinician to
explain to the judge the severity of the client’s
symptoms and to indicate that the car accident is
the cause of those symptoms. The clinician believed
that he knew the client well and wanted
to help the client with his case; he also was
somewhat concerned that refusing the client at
this point in treatment might anger him and
undermine the alliance. He wrote the letter and
soon found himself subpoenaed to a deposition,
in which opposing counsel aggressively grilled
him about his level of graduate and postgraduate
supervised forensic training (of which the
clinician had none), his experience and knowledge
regarding the tools used to assess trauma
(which he had not used), and whether he had
assessed the client for symptoms prior to the
accident (which he had not done).
In this situation, the clinician’s desire to help
and concern over the impact of his refusing to
do so made it easy for him to miss a subtle, yet
real, shift in his role as the treating psychotherapist,
and an equally important issue of the
requirement for a different set of skills and
competences needed to engage in this extratherapeutic
activity. In particular, he agreed to
provide a forensic opinion—essentially shifting
him into an expert role. It is important for the
clinician to recognize the limits of his competence
in this kind of scenario. Most clinicians do
not have forensic training or expertise. Even if
this professional had the appropriate skills to
render him technically competent, he did not
conduct an objective forensic evaluation that
would allow him to offer an opinion about the
cause or severity of symptoms relative to the car
accident.
This scenario also illustrates a common multiple
role challenge for the clinician: being
asked to move beyond a psychotherapist role
and assume a concurrent forensic evaluator role,
which can significantly affect the clinician’s
emotional competence and objectivity. This role
shift risks disrupting the therapy; for example,
the client may become angry at the therapist
when his or her testimony inadvertently weakens
the client’s case because of the very limited
nature of the underlying data. Such an outcome
heightens the likelihood of an accusation
of an ethics violation and a potential board
complaint.
Thus, when asked to engage in activities beyond
the typical bounds of psychotherapeutic
services, clinicians must recognize the issue of
competency boundaries and the potential for
conflicts of interest (Knapp et al., 2017b).
Rather than reflexively agreeing to help, clinicians
can stay grounded in ethical practices and
lower their risk by slowing the decision-making
process, engaging in self-reflection (Knapp et
al., 2017a) and asking themselves whether the
actions being requested would take them beyond
their training and education, require information
beyond that which would typically be
available to treating clinicians, or create another
role that could conflict with treatment (Pope &
Keith-Spiegel, 2008). If unsure, we advise clinicians
to take time to research the question
further and to ask for consultation from a
knowledgeable colleague—methods that can
significantly improve the ability to stay within
the bounds of one’s competence—as would
consideration of alternative means of addressing
clients’ requests, so as to maintain or even
strengthen the alliance, such as helping them
locate a professional who could take on the role
of a forensic evaluator.
278 TAUBE, SCROPPO, AND ZELECHOSKI
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Have Basic Knowledge About Legal
Aspects of Mental Health Services in One’s
Jurisdiction but Do Not Assume Mastery
Being aware of basic legal parameters can
help clinicians to avoid making errors in this
complex arena. Yet clinicians are not usually
lawyers and tend to have only limited legal
knowledge. This gives rise to a risk of assuming
more mastery than one may have. Indeed, research
suggests that a range of professionals,
including psychotherapists, overestimate their
capabilities and competencies, even in areas in
which they have received substantial training
(Creed, Wolk, Feinberg, Evans, & Beck, 2016;
Lipsett, Harris, & Downing, 2011; Mathieson,
Barnfield, & Beaumont, 2009; Walfish, McAlister,
O’Donnell, & Lambert, 2012). The consequences
of such overestimates can be significant,
particularly in the legal context.
For example, a mental health professional
was working with a woman regarding her longstanding
depression. The client had sustained a
fall on a sidewalk outside of a grocery store in
her neighborhood. She sued the store, claiming
that the fall had caused a significant exacerbation
of her emotional problems. The clinician
had had some initial forensic training in her
graduate program a few years before and knew
that, in her state, when a person raised their
emotional condition in a lawsuit, they waived
privilege. Thus, when the clinician received a
subpoena for her client’s records from the shopping
center attorneys, she believed privilege did
not apply, and she had no choice but make
copies of the records and send them to opposing
counsel. When her client discovered that the
opposing side had her treatment records and the
professional had not asked her permission to
disclose them, she became very upset and filed
a licensing board complaint. The board found
that the professional had violated her duty to
maintain confidentiality, should have at least
contacted the client, and, perhaps, should have
consulted with an attorney prior to releasing the
records.
In this situation, the professional had assumed
that her legally related knowledge about
the application of privilege was sufficient and
that, because a lawyer demanded something
(here, her records; but it could be her time, a
letter, a meeting, etc.), she had to provide it.
Subpoenas generally do require a response, but
the first step is usually not to immediately comply
with the demands. Rather, the best initial
response would be to protect the client’s confidentiality
and contact the client to determine her
wishes (thus, honoring her autonomy) and recognize
that the professional may not have complete
information about the legal context, even
when privilege may have been waived (see, e.g.,
Rost v. State Board of Psychology, 1995). If the
client wants the records disclosed, the professional
would have her sign an authorization to
do so. If not, the clinician would assert the
client’s privilege (i.e., a right to confidentiality
in this special therapist– client relationship) and
let the court decide. We have found that it helps
to have a skeptical attitude toward requests from
lawyers and, even when clinicians have some
legal or forensic experience and knowledge, to
confirm their understanding with knowledgeable
colleagues or an RM consultant. Had the
clinician not assumed that her knowledge was
sufficient, but rather considered its possible limitations,
she could have avoided disrupting this
treatment relationship and causing herself legal
problems.
Keep Good Records
Good documentation has multiple functions
(e.g., continuity of care, establishing medical
necessity for the purposes of reimbursement),
but it is axiomatic that it serves a crucial RM
purpose (Knapp et al., 2013; Soisson, Vande-
Creek, & Knapp, 1987). Ethics codes (e.g.,
ACA, 2014, Section A.1.b; APA, 2017, Standard
6.01) and licensing statutes and regulations
often require that records be developed and
maintained, without which one can become subject
to discipline. And when high-risk situations
occur, the nature and extent of the professional’s
documentation is often the main defense
against allegations that the clinician fell below
the standard of care (Knapp et al., 2013;
Woody, 2013).
For example, an experienced clinician had
been working with a client who was intermittently
suicidal. He routinely assessed her in
session and had recently determined that there
was no imminent risk. Still, because of her
history of nonlethal attempts when she had been
in a similar emotional state, he decided to set up
times for a daily check-in with her during the
NINE RISK MANAGEMENT LESSONS 279
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following week. He called each day as they had
planned; on the fourth day, he called, and she
did not pick up. He called again, with no result;
so, as they had agreed upon, he called the local
police for a welfare check. When they arrived at
the client’s home, they found that she had died
of an overdose. The clinician was soon contacted
by her husband, the executor of her estate,
who asked to see the records. The clinician,
though very cautious about assessment and
safety planning, did not have notes about his
assessment process, outcome, and reasoning.
The widower then threatened to sue.
Though it is not very likely that outpatient
clinicians who lose a client to suicide will be
sued, the absence of records creates significant
vulnerability. It means that there is no nearcontemporaneous
evidence of what the professional
assessed, how they did so, what their
results were, and the reasoning that underlay the
clinical decisions they made. It also means that
no evidence exists about their follow-through.
This not only likely violates the standard of care
in itself (see, e.g., Abille v. U.S., 1980) but, if
the clinician’s judgment is later questioned, it
also substantially increases the likelihood that
they will be perceived as now reporting their
past “careful” clinical judgments in a selfserving
manner only to avoid liability, rather
than having actually engaged in such thought
processes at the time of the events, and as
reflected in regular documentation. Thus, engaging
in thoughtful, yet routine, documentation
of clinical services, supervision, and consultation
is a core RM lesson, as is the addition
of details to those records when risky situations
arise.
Regularly Seek and Use Consultation
Consultation has been defined as the provision
of assistance by one professional to another
in which the person obtaining the assistance
maintains full responsibility for the services she
or he provides (Alban & Frankel, 2007; Goodyear
& Rodolfa, 2012; Knapp et al., 2017).
Engaging in consultation with peers and others
is a cornerstone RM technique that has a number
of potentially positive effects (Gottlieb,
Handelsman, & Knapp, 2013; Knapp et al.,
2013). It provides the clinician with the opportunity
to gain additional relevant regulatory,
ethical, and practical information that may clarify
her or his best course of action (Knapp et al.,
2017). Consultation can expand the professional’s
range of possible approaches to the problem
and helps prevent “tunnel vision.” In addition,
consultation serves to distribute and widen the
circle of responsibility for addressing and resolving
the problem, which decreases individual
burden on the professional. It can also assist the
practitioner in reflecting upon and regulating his
or her emotional response to challenging situations
(Knapp et al., 2017). Finally, consultation
helps to establish that the clinician has met the
standard of care. As Gutheil (2005) put it, clinicians
should have a “low threshold” for seeking
consultation (p. 480).
Clinicians are most at risk of failing to obtain
consultation when they (a) lack the specific
knowledge necessary to satisfactorily resolve an
important problem; (b) are being pressured by
clients, peers, or superiors to make an immediate
decision about the problem; and (c) believe
others will view them as professionally inadequate
if they ask for help.
Consider, for example, the following scenario:
A psychotherapist who works at a college
counseling center received a demand from an
academic dean to immediately release treatment
information about a student whom the psychotherapist
was treating. The dean stated that the
college needed the information to effectively
defend itself against the student’s/client’s reported
threat to sue the college. The laws, rules,
and policies that govern the release of such
treatment information were complex and involved
an analysis of the Federal Educational
Rights and Privacy Act (1974), state law, and
the college’s own policies and procedures. Instead
of trying to determine on her own whether
to release the records to the dean or to assert that
the records are protected from disclosure, the
professional, after indicating the nature of her
concerns about confidentiality, would have been
wise to suggest to the dean, in writing, that they
consult with legal counsel knowledgeable in
educational and mental health law as well as the
ethical and regulatory constraints that are imposed
by licensing boards. By doing so, the
psychotherapist would have drawn the organization’s
attention to potential ethical, regulatory,
and legal problems, and dispersed responsibility
for its resolution among multiple parties,
including those who were more likely to have
280 TAUBE, SCROPPO, AND ZELECHOSKI
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the requisite knowledge to adequately address
the problem.
Although this may seem like an obvious example,
as consultants, we frequently hear from
professionals who, in the heat of the moment
and under pressure from clients, peers or superiors,
take quick, but uninformed, action without
first seeking input from colleagues. Consultation
is most critical at precisely such times.
Indeed, it is relatively rare for clinicians to have
to react immediately to a client or administrator
request. More commonly, the clinician can take
the time to reach out to a knowledgeable consultant
before giving an answer. Simply informing
the dean or the client, for example, that the
clinician will give serious consideration to the
request and respond soon can allow time to
consult and deliberate, and increases the likelihood
of offering a more informed, thoughtful
response. Ideally, the professional will document
the consultation so that there is less likelihood
of a dispute later about what she and her
consultants knew and did about the problem.
The pool of potential consultants can be quite
broad and might include the psychotherapist’s
supervisor or boss, institutional administrators,
other practitioners professionally involved with
the client (e.g., the primary care physician or
psychiatrist), legal counsel, risk managers, and
even the client’s family members (if clinically
indicated and with client authorization). The
professional, however, should be cautious about
consulting with persons who are unlikely to
possess relevant professional knowledge and
who bear no direct or indirect responsibility for
the situation. For example, consultations with
one’s own family members, administrative
staff, or anonymous listserv members are likely
to be of little value.
Note, however, that there are situations in
which consultation may actually increase the
clinician’s risk. This is most likely to occur
when the professional has already taken an action
and is now seeking to justify or defend it. A
psychotherapist, for example, who receives a
board complaint or who is notified of a client’s
suicide would be wise to limit consultation because
his or her statements to others are potentially
discoverable in the course of formal investigation
or legal action. In such cases, the
psychotherapist should consult with an attorney,
RM consultant, or with his or her own treating
psychotherapist so that these communications
remain privileged and protected from discovery.
Conclusion
There are a range of client and situation characteristics,
as well as practitioner limitations,
that give rise to risks in professional practice.
Being aware of such risks and developing a
repertoire of strategies through which to manage
them are essential to the creation and maintenance
of a productive professional career. A
foundation in ethical principles is essential, but
it is not sufficient. As is the case in all treatment
approaches, skills in structuring services,
awareness of competencies, intuitions, and affective
responses, and a reflective, thoughtful
approach to stress and difficulties are also important
in mitigating risk aspects of professional
life. So, too, is a willingness to routinely seek
and use consultation. Attention to these dimensions
of our work is not based in a single event
or completed when one moves into the middle
or advanced phases of professional life. They
reflect a set of practices and approaches that
require ongoing application throughout one’s
career—especially when the “hair on the back
of your neck stands up” (E. Harris, personal
communication, 2014).
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Received December 6, 2017
Revision received June 29, 2018
Accepted July 2, 2018
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