Issues

• Seeking comments concerning ethical and legal issues when treating mandated clients for substance abuse by unkown, 3/18/99
  
  

I hope a lot of people comment about this. ... Treatment in mandated settings -- and others in which there is a conflict of interest with, say, an employer (such as many EAPs) is harder than it looks. ... One thing I always do is clarify, in writing or documented in chart notes -- FIRST with the agency for whom I am working (if it's not a private referral) and THEN with the patient/client -- exactly what my duty is to the referring agency. Accept the fact that there is a conflict of interest (really nothing new to most of us), be sure everyone knows what it is, and work with it. ... I DO NOT recommend telling the patient/client that "even though I'm working for the (prison, probation department, employer, school, training program, etc.) you don't have to worry about that; everything you say is confidential," etc. There may well be times when you need to report something (such as suicide danger, substance use, medication or therapy noncompliance, etc.) ... Referring agencies, such as a licensing board, often give you authority to keep some things confidential (such as treatment details), but be sure those are spelled out. ... When the patient/client says he can't work without complete confidentiality (or while under threat of something from the referrer), I treat that as, at least in part, a resistance or manipulation. When he or she tries to get me to agree to some "special" or "secret" item and keep it outside the agency relationship, I treat that as a resistance as well, and never do it. The treatment is affected, of course, but I want the patient/client to agree to do what we can. ... When the referrer wants periodic reports, I notify the patient/client but I DO NOT let the patient/client edit them. I have no problem with discussing such reports, but I try not to allow them to become resistances or foster manipulation. He or she may or may not be entitled to a copy. Many therapists go over such reports with the patient/client before they are submitted. When I do so, it is with the understanding that it for information, not for any changes; after all, the report is part of your relationship with the referrer, not the patient/client. Is it a dual relationship, with conflicts of interest? Sure. ... Finally, perhaps the biggest conflict comes when the therapist has to make some recommendation and the referring agency expects objectivity. I have strong feelings about our ability to comment objectively once we have a clinician-patient relationship (or clinician-client relationship). Nevertheless, the agency has a right to expect you to be objective about, for example, whether or not the patient/client can practice competently, teach safely, pilot a plane full of people, be released on the public, etc. You might recommend that the agency choose a DIFFERENT professional for such an evaluation, then give that person access to all the records. Similarly, I usually suggest that such "enforcement" actions as urine testing for drugs be done by someone other than the therapist. ... There is so much in this question that I wasn't going to comment much, leaving it up to others. Fat chance. But other people have far broader experience to contribute than I.

• More questions concerning ethical issues by unknown, 3/22/99