Samuel Knapp, EdD, ABPP, Michael C. Gottlieb, PhD, and Mitchell M. Handelsman, PhD
Professional associations often recommend consultation as an essential activity to ensure competence. Although consultation differs from supervision and includes generally few legal risks to the consultants, consulting psychologists should nonetheless strive to promote the effectiveness of the consultee’s practice. Few data exist to guide psychologists who are asked to be, or want to be, paid consultants, but we can offer suggestions based on our experience as consultants. We urge consulting psychologists to pay special attention to informed consent, maintaining appropriate boundaries, and ensuring that they remain within their boundaries of professional competence.
Dr. Doe is a licensed psychologist who has a well-deserved reputation as a specialist in child abuse cases. One day she received a call from another licensed psychologist, whom she had once met briefly, asking for an hour of her time for a consultation. “I am willing to pay for the service. I have a very delicate case that deals with child abuse, and I need some guidance.” Dr. Doe has supervised interns and postdoctoral trainees before and has done some adjunct teaching at a local university. She has provided brief, informal consultations to colleagues she knows well, but she has never engaged in a formal paid consultation relationship before. What factors should she consider?
In this article, we will provide some background information and then review basic information that Dr. Doe should consider before taking the case. We have divided this information into three primary factors: informed consent, roles and boundaries, and competence. We begin with an overview of consultation.
Background: What is Consultation?
Consultation differs from supervision. Consultants can offer their opinions, but consultees retain control over all their decisions and have the option of following, modifying, or ignoring the recommendations of their consultant. Literally, the term “peer consultation” that we used in the title of this article is redundant because consultants are peers, at least in the sense of having the same legal authority. Consultants have no legal authority to direct the professional activities or usurp the clinical judgment of the consultee. In contrast, supervision is a hierarchical relationship in which the supervisor retains ultimate authority over all treatment decisions, and supervisees should not modify or ignore the directions of their supervisors. Consultation involves few legal risks because the consultee retains complete authority to decide how to respond to the case. In contrast, during supervision, the supervisor assumes full legal responsibility for the case. To avoid any confusion between supervision and consultation, we recommend that consultants only enter into a consulting relationship with professionals who hold a license for the independent practice of their profession.
This distinction between supervision and consultation has important implications for malpractice and professional liability. We are not aware of any case law where a consultant was held liable for the actions of a consultee. This makes sense from a public policy perspective that encourages consultation, because the quality of health care can be improved when professionals consult with peers. Although the risk of professional liability is remote, consultants will nonetheless want to provide a high quality of service, partially by attending to the suggestions we offer below.
Consultation figures prominently in the APA Ethical Principles of Psychologists and Code of Conduct (APA Ethics Code, APA, 2010) and other guidelines (e.g., APA, 2007, 2014). General Principle B (Fidelity) of the APA Ethics Code states, “Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work.” Several enforceable Standards within the APA Ethics Code identify consultation as one way psychologists can ensure the quality of their work. For example, Standard 2.06 requires psychologists to obtain consultation if they have a mental or physical condition that threatens their professional competence. Standard 2.01 identifies consultation as one way psychologists can determine their competence.
APA guidelines often refer to consultation as a needed avenue to provide adequate professional services (see, for example, guidelines for working with older adults; APA, 2014, Guideline 2). In addition, consultation is highly recommended for risk management (Knapp, Younggren, VandeCreek, Harris, & Martin, 2013) and for improving the overall quality of services (Johnson, Barnett, Elman, Forrest, & Kaslow, 2012; Knapp, Gottlieb, & Handelsman, 2015).
Additionally, the APA Ethics Code has two statements related to the confidentiality of consultations. First, Standard 4.06 (Consultation) allows psychologists to consult on cases without a release of information from the patient if they did not exchange identifiable patient information. Also the APA Ethics Code (Standard 1.05) does not require psychologists who review the work of others, such as through a consultation relationship, to report ethics violations. Although most state boards of psychology adopt the APA Ethics Code as binding on its licensees, not all do. Therefore, psychologists need to know the relevant rules in their jurisdiction prior to serving in this capacity.
Finally, the APA Ethics Code appears to require consultants or consultees to keep notes (APA, 2010, Standard 6.01) if it is necessary to “facilitate provision of services later by them or by other professionals.” This requires some judgment on the part of the consultees (or the consultants) as to when and what to document. Most consultations are brief and single events. The consultation occurs and the psychologist never hears about the situation again except for perhaps a courtesy follow-up. Our interpretation is that consultee psychologists and their patients would seldom benefit from documenting very brief or routine consultations. However, we can easily envision documentation facilitating the provision of services when the consultations are more complex. No specific standards address the length of time for keeping consultation records. A useful guideline to follow would be to keep records for consultation for the same length of time as the jurisdiction requires for psychotherapy patients.
APA guidelines often refer to consultation as a needed avenue to provide adequate professional services . . . In addition, consultation is highly recommended for risk management and for improving the overall quality of services.
Many psychologists consult with psychologists or other professionals who work out of state. Interstate restrictions on practice are based on the assumptions that the patient is receiving services from a professional in the state in which both reside. However, consulting psychologists are not providing psychological services to patients, and we know of no psychologist who was ever disciplined for providing consultation to a psychologist across state lines. Nevertheless, consultants should be aware that laws across jurisdictions may differ, and consultants need to take account of those potential legal differences.
Types of Consultations
Some consultations may be brief and simple. For example, a psychologist may be dealing with an uncomplicated case and simply need information that can be handled in a brief phone call or a single short meeting. Often psychologists do not charge, or even consider charging, for such brief and informal consultations.
Another form of consultation that would not involve financial exchange is a so-called peer supervision group. This name is somewhat misleading as it is not technically “supervision,” but rather a group of peers mutually sharing and discussing interesting or challenging clinical cases. Some practitioners regularly attend such peer consultation groups, which often continue for years. Although we know of no empirical data to support the value of this practice, those who participate in such groups often assess them positively and believe that the support of, and assistance from, their peers helps improve the quality of their work.
However, in two types of situations one psychologist would probably pay another psychologist for consultation. Some psychologists may want to expand their scope of practice into a related field. For example, a psychologist with experience in child psychotherapy may have recently received additional training to become a child custody evaluator and desire feedback or guidance from a consultant in this new role. That relationship may require weekly meetings over a period of months, involve directly reviewing near final reports to the court, and include recommendations for further didactic learning experiences.
Other psychologists are willing to pay for consultation on a particularly difficult matter, such as in the case of Dr. Doe referenced above. We recommend that Dr. Doe consider three important factors: informed consent, roles and boundaries, and professional competence, before accepting the consultation relationship.
Informed consent is a basic element of all professional relationships, although not always explicitly acknowledged and formally addressed. Because the roles of consultant and supervisor can be confused, we recommend that the consultant briefly note the difference between consultation and supervision, including the potential limits on confidentiality and lines of professional responsibility.
Psychologists need to make known their fees “as early as is feasible” (APA, 2010, Standard 6.04), which usually means ahead of time. An hour of consultation time seems rather straightforward, but consultants may wish to build in some time to write notes for themselves, especially if the case is especially complex. Also, some consultations may require follow-up phone calls. Few psychologists would begrudge five minutes of their time for a brief call. However, in more complex cases multiple follow-up consultations may be necessary. Some psychologists will establish a minimum amount for a follow-up call (for example, the equivalent of 15 minutes of their time). They can always waive the costs of a very brief call if they find that the consultee is using their time wisely.
A formal contract may not be necessary, but we suggest that consultants draft a brief letter that includes the essential elements discussed here. It need not be complex, but it could include the purpose of the meeting (e.g., consultation to help the consultee make clinical or ethical decisions), limits on confidentiality, and any fees involved. It should also clarify that consultation differs from supervision, that the consultant will have no direct contact or professional relationship with the patient, and that any party has the right to terminate the relationship at will. We think it is reasonable to keep the parameters of the consultation open because issues may emerge that were not obvious when the agreement was first reached. The only exception would be a situation in which the consultant does not know the applicable laws or rules regulating the practice of the consultee’s profession. This may occur, for example, when a psychologist supervises a member of another profession or supervises a psychologist practicing in another state.
As with psychotherapy, it is helpful to think of informed consent as a process, even in an apparently short consultation, because the features and goals of the situation may change as additional information becomes available. For example, Dr. Doe might find that the case is far more complex than the consultee first thought and may necessitate on-going work.
Roles and Boundaries
Psychologists who enter a paid consultant relationship should clarify the roles of each party, distinguish between consultation and supervision (as noted above), and determine when a consulting relationship is contraindicated because of previous friendships between consultants and consultees.
Supervision and Consultation
Consultants want to ensure that the consultee has realistic expectations of the services that they will provide. For example, consultees should clearly distinguish between consultation and supervision that we discussed above. We can illustrate the importance of this clarification through two examples based on our experiences. We are aware of situations where psychologists received phone calls from licensed professional counselors who wanted “consultation” on a case. However, upon further discussion it became clear that they wanted the psychologists to sign a treatment note or billing form indicating that they were supervising a case, whereupon the counselor then expected to submit bills to third party payers for reimbursement. In this example, counselors were asking for supervision, and the psychologists would become legally responsible for the case. The professional counselors would surrender their professional autonomy—something that few professional counselors would want to do. Furthermore, few commercial insurers have policies that reimburse for supervised services—a fact that the professional counselors did not know or thought that they could circumvent.
Conversely, we know of another case where an agency was the subject of a licensing board complaint filed by one of its patients. During the investigation, the well-meaning but ill-informed agency director noted that the case was supervised by a licensed psychologist. In reality, the psychologist had virtually nothing to do with the case, except that he once provided consultation to the agency on it (even though his advice was ignored). Fortunately, the psychologist produced his letter of engagement, which clearly specified that his was a consulting relationship, and the case against him was quickly dismissed.
Multiple Relationships and Consultation
Quick, informal, information-based consultations often take place among colleagues who are also good friends or have social relationships with each other. Even when more intense consultations are necessary, one could argue that knowing the skills of a consultee by being their previous supervisor or teacher, knowing them as a colleague, or being their friend may sometimes provide information that increases the usefulness of the consultation. However, this is not always the case. The more complex the consultation (and payment is evidence of such intensity), the more the consultant needs to be aware of professional boundaries. One of us (MH) even goes to the extreme and jokes that psychologists should seek consultation “from someone you hate.” We do not wish to set an arbitrary set of rules that precludes consultations based on past relationships, but in some cases, the multiple relationships or boundary crossings might blind consultants to shortcomings of the consultee or cause them to blunt criticism that should be direct and unambiguous.
It is flattering to be asked for a consultation, but effective consultants need to consider whether they are competent to provide the service requested. Our review of the literature has failed to identify any predetermined skill sets for consultants, let alone identify how those skills should be operationalized. Nonetheless, we offer some suggestions from our experience on how to determine one’s competence in consultation; they involve knowledge, skills, and attitudes.
Consultants need to have knowledge relevant to the case. Many areas of practice have become so specialized that not anyone will do as a consultant. For example, geropsychologists would not ordinarily consult to psychologists working with children (unless some unusual grandparent issues had arisen). However, even within an age group, a psychologist who is competent in adult outpatient work might not necessarily have the competence to deal with a patient with a serious personality disorder. Competence in an area of practice also includes knowledge of professional norms and relevant laws. In Dr. Doe’s example at the beginning of this article, we noted that it involved a case of child abuse. Part of the expertise of a consultant in this case would be knowledge of the child abuse reporting laws in the jurisdiction of practice. At times, consultants need to acknowledge the limits of their knowledge base and refuse a case.
The more complex the consultation . . . the more the consultant needs to be aware of professional boundaries.
Our impression is that consultants can usually present their areas of competence in a straightforward manner through a brief conversation. Of course, at times, consultants may come to realize over time that their skills are not sufficient to handle the case. A consultant may accept a case dealing with a depressed patient only to learn, through the course of time, that the patient also has a co-existing untreated and unrecognized substance use disorder. It is possible that the consultants would then need to acknowledge the limits of their knowledge and urge the consultee to get additional assistance from another source. Consultants should not be afraid to say, “I do not know,” or, “You need to get additional consultation from somebody else on that particular issue.” Consultants may also make a referral when ethical or legal issues arise that are beyond their expertise.
Consultants should have the interpersonal skills needed to deal directly with a consultee who may be distressed and anxious. Sometimes consultees need nothing more than direct information. For example, consultants could inform consultees of relevant assessment instruments, preferred therapeutic approaches, or relevant legal issues. However, the most important skill is usually the ability to listen. Consultants should ensure that they have all the relevant information before they give an opinion. Often, skilled consultants will present their initial impressions tentatively, and encourage consultees to challenge that opinion if they choose.
At other times, consultees, perhaps overwhelmed by their situation, may flit from one issue to another without a coherent sense of priorities or direction. When consultees feel this much distress, part of the consultant’s job may be to calm them down and help them think through the issues. Their job may even include a referral for personal therapy. When consultees are especially overwhelmed or disjointed, it may be necessary to be more directive, at least at first, until the consultees can control their emotions well enough to clarify the professional issues.
When consultees appear to be withholding information out of fear of embarrassment, consultants can make it easier for them to disclose essential information by adopting a non-judgmental attitude.
However, we contend that the default position for effective consultation is to adopt a collaborative model to help consultees think through issues and clarify their goals. Collaborative relationships are typically transparent. That is, consultants explain the reasons for their recommendations with the goal of helping consultees understand the basis for them. For example, it would not be sufficient to say that a patient needs psychological testing without further explanation. Instead, it would be far better to say that the patient needs psychological testing because it can measure certain traits that interviewing alone may not be able to capture. Part of this transparency may also involve explaining why the consultant asked certain questions. For example, the consultant might say, “The reason I am asking about these behaviors is that attention deficit disorders are often co-morbid with autism.”
Similarly, collaborative consultants can ask their consultees to discuss their reasoning as well. This will help the consultant better understand the thought process of the consultee and alert the consultant to any illogical or nonrational processes on the part of the consultee. Rogerson, Gottlieb, Handelsman, Knapp, & Younggren (2011) outlined some nonrational factors that consultants need to be aware of. For example, anxiety might lead consultees to provide their clients premature advice simply to reduce the distress that arises from ambiguity. Or, consultees may be subject to confirmation bias, coming to a quick conclusion about what the issues are or what should be done and seeking consultation simply to obtain support for their decision. (Of course, consultants themselves are not immune from such nonrational factors.)
Consultants may be more effective when they help consultees think through their options and develop a solution or a path to a solution that they feel comfortable with and which would fit into their overall treatment of the patient and their theoretical model. This may mean, for example, laying out a variety of options for the consultee, including some that are clearly wrong. For example, there may be clinical reasons to think that this patient might benefit from thought stopping exercises. However, such an intervention might be contraindicated if the patient is receiving acceptance and commitment therapy. By laying out many options, the consultee can discuss and narrow the options and retains greater control over the process. It also provides the consultant with additional insight regarding how the consultee thinks about the issues and what nonrational factors might be operating.
Consultants should be prepared for unexpected complications. Gottlieb et al. (2013) created a ranking of four levels of consultations according to the complexities of the case, with the lowest being a simple request for straightforward factual information, which is typically given as a courtesy to a colleague. Consultations get more complex if consultees are unaware of important information relevant to the case, or if they are extremely distressed and are having difficulty thinking clearly about the case. The highest level of complexity involves a complex case where the consultee is unaware of the legal/ethical issues and is resistant to learning basic information about professional standards or treatment practices.
The consultants for the TRUST (formerly the APA Insurance Trust; Knapp et al., 2013) reported that most consultees appear to bring forth facts conscientiously and honestly. Nonetheless, some consultees enter with a predetermined set of ideas, and they want substantiation for their preexisting decision. Other consultees may withhold some information, perhaps out of embarrassment or shame at a mistake or perceived mistake that they may have made. When consultees appear to be withholding information out of fear of embarrassment, consultants can make it easier for them to disclose essential information by adopting a non-judgmental attitude. They can also normalize the possibility of clinical errors by describing situations where they avoided serious mistakes themselves by double-checking their work or having meaningful consultations with colleagues.
Still other consultees may lack some very basic knowledge of the subject area, yet think that they are competent (or even very good). In each of these situations, consultants will need to modify their manner of dealing with the consultee to accommodate the demands of the situation.
When consultees appear to want only substantiation of a previous decision, consultants are well advised to slow down the pace of discussion. They can preface their consultation by noting that confirmation bias is a common source of clinical mistakes (Sanders, 2009). Consultants can then proceed to question assumptions, ask for secondary sources to support conclusions, and so on. If consultants believe that consultees are not listening to them with an open mind, it may be helpful for them to ask the consultees to repeat their advice back to them.
At times, of course, consultants need to be clear about the seriousness of consultees’ mistakes. Some psychologists will be delivering less-than-adequate care, but believe strongly that their services are adequate or even exemplary. Most people see themselves through rose-colored glasses and overestimate their competence. This has been called the “better-than-average effect” (e.g., Epley & Dunning, 2006), and psychologists are not immune to this effect. For example, Walfish, McAlister, O’Donnell, and Lambert (2012) found that mental health professionals gave themselves a mean ranking of competence at the 80th percentile (the modal ranking was the 75th percentile). Similarly, Storey (2016) found that all psychotherapists rated themselves in the top half of skill. A modest overestimation of one’s skill level is probably innocuous enough, but sometimes consultants will encounter professionals who are grossly incompetent and yet perceive themselves to be doing well.
Although the APA Ethics Code does not mandate reporting of substandard conduct on the part of a consultee, we nonetheless urge consultants to take actions to remediate or at least mitigate potential harm to patients. When consultants learn of incompetent behavior, we suggest that they clarify the expected standards of good professional performance. Such complex situations may require special interpersonal skills, including helping consultees reflect on their professional behaviors. This often means being highly tactful when delivering negative feedback. However, tactfulness is subservient to the goal of promoting good standards of conduct.
For example, one of us (SJK) once encountered a psychologist who was using an outdated form of a psychological test (the test had gone through two subsequent revisions) with no clinical justification for doing so. The data supporting the older version was not superior to the data for the most current version, and there was no need to gather longitudinal data on a patient who had taken an earlier version of the test (see APA, 2010, Standard 9.08). At first, the consultee seemed impervious to these concerns, but eventually he understood and agreed. But what if he had not? In such circumstances, we suggest that the consultant write a letter to him documenting the concern that his use of an outdated test risked delivering less-than-adequate services and presented liability risks for him as well. As we noted above, we recommend that the agreement allow consultants to terminate their relationship at any time, and this may occur if the consultee is noncompliant with very basic standards of professional conduct.
Consultants need to remember that they do not have the ultimate responsibility for the case and need to accept their limited role. Consultees may not agree with or value the comments of consultants and will ignore them. We think that it is often necessary to voice the limited nature of the consultant’s role by saying something such as, “This is what I would do,” because it is important to respect the consultee who must make the final decisions and live with them.
Summary and Recommendations
We have identified three major issues that Dr. Doe should consider before accepting a paid consulting assignment. First, it is useful to clarify roles, limits on confidentiality, amount and method of payment, and expected responsibilities. We would not recommend limiting the scope of the consultation in the agreement letter except as it pertains to the laws regulating a member of another profession or a psychologist practicing in another state. Payment arrangements should consider time for any note taking by the consultant and for follow-up phone calls. A letter of agreement documenting these issues may be appropriate.
Second, Dr. Doe, like any consultant, should be mindful of her role. We recommend clarification between consultation and supervision. Consultants may be “friendly” with their consultees, and some consultation relationships with friends or colleagues can be productive. However, consultants should be alert to the possibility that past relationships and current boundary crossings may compromise their objectivity.
Finally, Dr. Doe, like any psychologist, should ensure that she is competent to deliver the desired consultation services, not only through knowledge of the subject matter, but also through an understanding of the types of interpersonal skills that are most likely to help the consultees improve the quality of their services. Our experience has been that most consultees are cooperative and open, and most consultations go well. However, consultants should be prepared to address complex issues and respond when they encounter substandard behavior by consultees. Usually, consultants will be able to assist consultees through direct, but tactful conversations. However, consultants may sometimes need to confront consultees with the inadequacy of the service provided and be prepared to withdraw from the consultation.
Samuel Knapp, EdD, ABPP, is the Director of Professional Affairs for the Pennsylvania Psychological Association. His major area of interest is in professional ethics. Samuel Knapp is the lead author of Practical Ethics for Psychologists: A Positive Approach and was the editor of APA's Handbook of Ethics in Psychology.
Michael C. Gottlieb, PhD, is a forensic and family psychologist in independent practice in Dallas, Texas. He is board certified (ABPP) in family psychology, a fellow of the American Psychological Association (APA), and a Clinical Professor at the University of Texas Southwestern Medical Center at Dallas. He is a past member of the APA Committee on Professional Practice and Standards and its Ethics Committee. His interests surround ethical decision making and the psychology/law interface.
Mitchell M. Handelsman, PhD, is Professor of Psychology and a CU President's Teaching Scholar at the University of Colorado Denver. His areas of scholarship include professional ethics and teaching. He is co-author of The Life of Charlie Burrell: Breaking the Color Barrier in Classical Music.
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