Clinical Ethics and Risk Management: A Process Approach to Working - - PowerPoint PPT Presentation
Suicide Prevention Lab Clinical Ethics and Risk Management: A Process Approach to Working with Suicidal Risk David A. Jobes, Ph.D., ABPP Professor of Psychology Associate Director of Clinical Training Director, Suicide Prevention Laboratory
Suicide Prevention Lab
David A. Jobes, Ph.D., ABPP Professor of Psychology Associate Director of Clinical Training Director, Suicide Prevention Laboratory The Catholic University of America National Register of Health Service Psychologists 2019 National Practice Conference Washington, DC 11/8/19
Just when you think you have seen it all, an odd, complex, unclear, and
confounded case comes along leaving you stumped and not sure how to proceed…
With ethics there is almost always a way to “play it safe”—erring on the side
best interest).
How do you feel about working in the “gray areas” of ethical decision-
making?
Historically there was some professional reluctance to developing ethics codes. This attitude changed dramatically after WW II and the Nuremburg Trials. Across disciplines our ethics codes have started very generally and become more
and more specific with each revision.
Generally speaking, about 90% of ethical codes across mental health disciplines
are essentially the same.
For example, consider the oldest of the mental health ethics codes, the APA
ethics…
Beneficence and Nonmalfeasance Fidelity and Responsibility Integrity Justice Respect for People’s Rights and Dignity
“Who is the client?” is too narrow of a focus for a larger ethical
sensibility.
Upon reflection, we have ethical obligations towards every party in a
case, no matter how many.
This requires identifying all relationships and related ethical
The better question: “What are my ethical responsibilities to each of the
parties in this case?”
Informed consent is a major focus in the professional ethics and risk management…
Informed consent should be obtained as early as feasible.
Consent should be a continuing process.
The nature of psychotherapy should be fully disclosed.
The anticipated course of treatment should be shared.
Fees and financial arrangements should be fully discussed.
Involvement of any third parties should be made clear.
The limits of confidentiality should be understood by the client.
HIPAA and documentation considerations should be disclosed.
Consent for new and untested treatments.
Competency to give consent (minors/adults).
Cultural sensitivity should be assured.
Consent and trainee therapists.
Sufficient information has been disclosed to make a fully informed decision
about treatment.
Participant was competent and consent was voluntary. Risks and benefits were fully reviewed. Put yourself in the patient’s place—what would you desire?
A clinician was sued for malpractice (wrongful death) after a 12- year-old boy that he met for five sessions hung himself in the family garage. The plaintiffs complained that the psychotherapist failed to appropriately assess, intervene, and provide adequate
that described the scope, limits, and various procedures of his practice completely swayed the jury that the clinician had in fact provided crucial information that was directly relevant to the claims of the parents. The jury deliberated for a half hour and found the clinician “not guilty” of malpractice.
where he is providing clinical and research consultation. His seat mate on the plan is a friendly and engaging member of the US
conversation about work life, family, sports teams, etc. While the psychologist is intent on doing some work during the flight, the seat mate continues to engage in conversation. The flight attendant comes through the cabin and the seatmate offers to buy the psychologist a drink…
another 4 month proposed treatment plan
“Trephination”
mentally ill from chains at Salpetrière an asylum for women in Paris (1795)
Hospital suicides: 1800/year ( Knoll, 2012) vs. 49-65/year (The Joint Commission, 2018) Highly critical views of Marsha Linehan and Matthew Large—i.e.,“Nosocomial suicides” which
are suicides that are caused by hospitalization!
Coyle, Shaver, and Linehan (2018)—potential iatrogenic effects of psychiatric crisis services Czyz, Berona, and King (2016)—readmission for suicidal teens significantly associated with
more severe suicidal trajectory and suicide attempts
Typical inpatient stay: medication and some brief group work of 5-6 days (NAMI, 2014) Hospitalization is associated with hundreds times greater risk for suicide deaths than general
population (Qin & Nordentoft, 2005; Large et al., 2011).
5% of all post-discharge suicide occur within a week of discharge (Pirkota et al., 2005) 20% of all post-discharge suicides occur within one year of discharge (Desai et al., 2005) Outpatients avoid talking about suicide for fear of hospitalization (Blanchard & Farber, 2018)
Mann et al (2005): Treating mood and the underlying psychiatric disorder is “…a central
component of suicide prevention.”
Un-replicated RCT evidence for lithium (Tondo et al., 2001) and clozapine (Meltzer et al.,
2003—only FDA approved Rx).
RCT’s not finding a SSRI effect on suicide ideation/behavior: Gunnell et al (2005) Ferusson et al (2005) RCT’s that did find a SSRI effect on suicide ideation/behavior: Zisook et al (2011) Gibbons et al (2012)
Limited RCT support for clozapine and lithium; very mixed results for SSRI’s…
Status quo—despite the lack of evidence it is just too hard to change our
mindset about hospitalization and medication (magical/wishful thinking)
Health plans insufficiently cover effective suicide care (no suicide diagnosis) Clinician fears about losing patients and particularly the fear of malpractice
litigation paralyzes providers and fosters a “better safe than sorry” defensive practice attitude
Training issues (implementation/dissemination)—actually getting clinicians to
use proven and effective treatments
The pervasive clinical care bias being the only approach that will work The vast majority of suicidal people reject mental health care The public relations battle—the general public and the media are still
insufficiently concerned about the magnitude of this major public health issue
* National Lifeline * Lethal means safety
1) Always provide Lifeline number 2) Always discuss access to lethal means 3) Verify that means have been secured 4) Consider providing your own number
Could differential assessments of different suicidal states lead to different “prescriptive” treatments?
Jobes (1995) Intra-psychic vs. Inter-psychic Agentic vs. Communal Conrad et al (2009) Acute vs. Chronic Kleiman & Nock, 2017 Ecological Momentary Assessment (EMA) Durkeim (1897) Egoistic Altruistic Anomic Fatalistic Possible DSM-6 Diagnosis? Rogers & Joiner (2017) Acute Suicidal Affective Disturbance Galynker (2017) Suicide Crisis Syndrome Josephine Au’s Latent Profile Analysis CUA
dissertation…
Wish to Live vs. Wish to Die Kovacs & Beck, 1977; Brown et al., 2005 Mayo Clinic Cross-Sectional Study O’Connor et al (2012) Bryan et al (2016)
LIFE MOTIVATION DEATH MOTIVATION RFL = RFD RFL < RFD RFL > RFD AMBIVALENT MOT.
A hybrid qualitative-quantitative approach
Written SSF responses and behavioral perseveration showing significantly increased ratings of suicidal risk across two clinical data sets (Hamadi, Colborn, Bell, Chalker, & Jobes, in press)
Suicidal people are thus not the same; treatments should therefore be tailored to different suicidal states… Lack of cognitive flexibility and loss of cognitive control was significantly associated with increased ratings and frequency
There are 80+ RCT’s with suicidal ideation and behavioral outcomes
There is no support for inpatient hospitalization; there is increased risk of suicide post-discharge
There are a handful of treatments with single RCT support in need of replication (e.g., ASSIP and mentalization-based therapy)
There are now well-studied suicide-specific interventions with replicated RCT support; these include:
Dialectical Behavior Therapy (DBT) Two types of suicide-specific CBT (CT-SP &
BCBT)
Collaborative Assessment and Management of
Suicidality (CAMS)
Non-demand follow-up “caring contact”
Dialectical Behavior Therapy (DBT) Cognitive Therapy for Suicide Prevention (CT-SP) Brief Cognitive Behavior Therapy (BCBT)
The four pillars of the CAMS framework: 1) Empathy 2) Collaboration 3) Honesty 4) Suicide-focused
Goal: Build a strong therapeutic alliance that increases patient- motivation; CAMS targets and treats patient-defined suicidal “drivers”
First session of CAMS—SSF Assessment, Stabilization Planning, Driver-Specific Treatment Planning, and HIPAA Documentation CAMS Interim Tracking Sessions CAMS Outcome/Disposition Session
Across 8 published non-randomized clinical trials of CAMS, 1 meta-analysis,
and 4 published randomized controlled clinical trials, and 1 unpublished RCT (a total of 70+ publications): CAMS quickly reduces suicidal ideation in 6-8 sessions CAMS reduces overall symptom distress, depression, hopelessness, and changes
suicidal cognitions
CAMS increases hope and improves clinical retention to care Patients like CAMS and the process of doing CAMS CAMS works better with less severe patients at baseline presentation (impact with
borderline patients is mixed)
CAMS decreases ED visits among certain subgroups CAMS appears to have a promising impact on self-harm behavior and suicide
attempts (but replication is needed)
CAMS is relatively easy to learn (adherence is typically attained with first patient)
Stephen O’Connor, Ph.D. A one-time psychological intervention on medical-surgical unit for attempters… Peter Britton, Ph.D. 1-2 sessions of Motivational Interviewing with veterans following a suicide attempt…
Konrad Michel, M.D. 3 session intervention focused on narrative interview, self-confrontation, safety plan, and follow up...
NIMH-funded V-CAMS prototype was feasible in “proof of concept” SBIR Phase I Patients engage “Dr. Dave,” peer-bridger videos, learn about coping skills, and receive psychoeducation about experience In NIMH-funded Phase II RCT patients will get: “Waiting Well Patient Dashboard” and “Caring Tools to Go Mobile Apps” to potentially avert unnecessary inpatient admissions providing post-discharge support (e.g., caring contact) The emerging tablet application is heavily influenced by lived-experience peers
41
Source: Motto & Bostrom, 2001
VA)
Consultation is a crucial professional activity. You should seek a release to communicate with previous providers. You should seek a release to communicate with consulting providers in
You should document information about your professional
consultations.
Know the differences between consultation and supervision.
Enacted by Congress in 1996, it came into effect April 2001; expected compliance was April 15, 2003.
The law has changed many aspects of professional practice.
Three Main Rules: 1.
Transaction Rule (electronic transmissions)
2.
Privacy Rule (P&P; patient information—PHI)
3.
Security Rule (physical infrastructure, offices, files, confidentiality, and communications)
If you do not write it down, it did not happen Write extensive initial medical record progress note Be sure to write session-by-session contemporaneous progress notes Try to write an extensive termination note (closing out the medical record)
Patient’s Name: John Doe Date/time seen: 3/ 3/17 9 am Payment: $600.00 Diagnosis: Adjustment Disorder/Depressed Mood—R/O substance abuse Presenting Complaint: Pt. still struggling with his wife over financial issues, has been tempted to drink but has resisted so far; work stress is interfering with sleep Mental Status: WNL; Generally stable, no evidence of suicidal thoughts—mood depressed Course of session: John is extremely stressed about work and home life. There have been various arguments and conflicts in marriage that interrupt his sleep and he feels irritable and more depressed/anxious. Yet, he has resisted temptation to drink and is using coping card/emotion regulation techniques effectively. Is eager to try medication and would like referral for couples therapy with wife. Treatment Plan: Continue in 1x/week psychotherapy, continue coping card/self-soothing techniques; begin Rx after meeting with Dr. Doe; refer to Dr. Smith for couples tx. Next appointment: STNW Signature: Joe Dokes, LCSW
Bennett et al (2006) on psychotherapy notes:
“…the confusion regarding the appropriate use of psychotherapy notes is partially a result of poor regulatory draftsmanship as well as a lack of guidance for when to use and when not to use psychotherapy notes. The Privacy Rule itself is somewhat vague about the psychotherapy notes…however, it is clear that psychotherapy notes must be kept separate from the general medical record…”
Medical record progress notes…
Must be contemporaneously maintained Should emphasize objective facts of the case These notes are always discoverable
Maintaining psychotherapy (personal) notes…
If allowed, you must physically store these notes separately from medical record
progress notes
There must not be overlapping information These kinds of notes—when permitted—may not be discoverable but can be
produced in your defense.
Written and signed consent for treatment Written treatment plan Relevant history—past or present evaluations Progress notes of sessions (significant events) Notes of calls/communications Notes of any consultations Diagnostic and treatment decision making No shows/cancellations Instructions patient did/did not follow Patients signed consent for disclosures Notes of the beginning, middle, and end of care
The importance of having “usual and customary practices” from a
professional and legal perspective.
For a range of tricky professional issues it always good to have a typical
way of handling things.
Written policies and procedures are always protective (unless one does not
follow them).
A clinical psychologist has worked with a highly dysregulated, anorexic, substance-abusing, and depressed health care provider with a significant trauma history. In the first three years of
apartment balcony prompted a longer-term hospitalization that was followed by admission to a residential substance abuse treatment program. Seeking consultation from a trusted psychologist colleague, the provider was stunned when the colleague gently suggested that perhaps it was unethical to continue working with a treatment plan that plainly was not
patient’s on-going suicidal risk.
Propose a major case review with the patient (and their family if
appropriate)
Consult with any collateral providers and trusted colleagues/experts about
treatment recommendations
Draft a summary report reviewing the work to date which concludes with
prospective treatment recommendations and requirements going forward.
Giving the patient/family three options:
To earnestly try a new treatment plan for finite period To take referral to another provider (for care or 2nd opinion) To take a break from treatment (if not in imminent danger)
Malpractice tort litigation for wrongful death secondary to a patient suicide is pursued by plaintiffs (e.g., surviving family) who assert that the provide breached the “standard of care”
The Standard of Care is operationally defined as what a reasonably prudent practitioner who is similarly trained, in a similar settings, with a similar patient would do.
Standard of care is defined by expert witnesses who examine subpoenaed records, interrogatories, and depositions
The plaintiff has the burden of proof to establish that the practitioner:
Failed to assess the risk (i.e., forseeability) Failed to appropriately treat the risk Failed to follow-through on risk over the course of treatment
Consultation and proof of consultation makes clear that you were not just on your
In terms of clinical documentation, any plaintiff’s attorney will tell you: “If it was
not written down, it didn’t happen…”
Recognize where trial lawyers are coming from—who they are and who they are
not…
Use the APA book by Brodsky on testifying in court.
Malpractice tort litigation is a plaintiff’s action whereby a list of complaints
are made about various acts of omission or commission by the clinician that are said to be a direct or proximate cause of significant client injury or death…
The clinician’s practice will be judged retrospectively by experts on both
sides of the case in relation to the “standard of care.”
Through a process of discovery and the taking of depositions, the case is
revealed—the burden of proof lies with the plaintiff.
Most plaintiff’s cases go nowhere; some settle, fewer still go to trial—you
never want to have to endure a malpractice trial as the defendant!
Malpractice Liability and Competent Practice (Jobes & Berman, 1993)
Know and practice in accordance with the three pillars of protection from
potential malpractice liability:
(a) Forseeability (assessment) (b) Treatment planning (c) Follow-up and follow-through
A thorough assessment was conducted Consider the possible use of assessment instruments Consider the possible use of psychological testing Make overall clinical judgments and document Seek professional consultation and document the consultation
Use overall assessment to inform and shape treatment plan Identify both short- and long-term treatment goals Consider range of treatments—what will be used and why? Consider various contingencies Routinely revise and up-date treatment plan Thoroughly document every aspect of the treatment plan Overhaul treatment plan when necessary Seek consultation and document the consultation
Ensure that treatments are being implemented Coordinate care with others as needed Be sure to seek release to talk to previous providers Always insure clinical coverage when unavailable Carefully make referrals and follow-up (issues of clinical abandonment) Seek consultation and adequately document follow-up and follow- through
care because of their attitudes towards mental health
something different than what they get (e.g., a more humanistic and person-centered response)
And the power of using technology to reach more suicidal people at risk…
Matching Interventions to Different Suicidal States
(Jobes & Chalker, 2019) Suicidal Populations (2017) Proven Interventions Universal Responses__________ (47K Suicide deaths)
10.6M Suicidal Ideators (SI) 1.4M Suicide Attempters (SA) Dysregulated BPD Multi-SA’s
______________________________________________________________________________________________________________________________
Suicidal—not seeking treatment
_______________________________________________________________________________________________________________
Stabilization Planning + Lifeline + Lethal Means Safety + Caring Contacts
CAMS CT-SP BCBT DBT Public Education + Lifeline + Caring Contact Machine Learning? Lived- Experienced Peer-Based Support?
CAMS MI, ASSIP, TMBI Stabilization Planning + Lethal Means Safety + caring follow-up used throughout the model DBT, CT-SP, BCBT Mental Health Service Corp—paraprofessionals (and people with lived experience) creating the necessary work force Suicide-focused care that is:
Email: jobes@cua.edu