Cuper, P. F.; Wise, E. H.; Clark, M.; and Shelton, S.
In this article, we present a series of vignettes highlighting ethical dilemmas from varied practice settings. This continues an exploration we began in the last edition of The Register Report (Wise, 2014), when we analyzed ethical problems that may arise when working in concert with colleagues in psychology or other healthcare professions. Our first vignette examines a psychologist’s ethical responsibilities when a potentially inappropriate request for accommodations is made by a client, our second on ethical difficulties that can arise in collaborative care settings, and the final vignette addresses dilemmas when an obviously impaired colleague with clearly impaired competence is unaware of or refuses to acknowledge limitations. Despite the obvious differences, these vignettes share a focus on the intersection between the ethics of professional practice and psychologists’ complex relationships with patients and colleagues from our own and other disciplines. As is the case with all but the most simple of ethical dilemmas in professional practice, there are no easy answers.
The Case of Ellen:
Responding to a Client’s Request for Assistance in Seeking Workplace Accommodations*
Drs. Cuper and Wise
The case of Ellen presents a dilemma that may be familiar to many psychologists: A client requests your assistance in asking for accommodations in the workplace, and you are unclear as to whether the request and/or the accommodations are: (1) in the client’s longer term best interest; and (2) fair to the employer or to other employees. Further, you may also believe that you don’t have sufficient evidence to attempt to intervene on behalf of your client. Responding to this request in a manner that is ethical, clinically useful, and does not damage your therapeutic relationship can be tricky.
Ellen is a 32-year-old divorced female. She lives with her parents and works as a certified nursing assistant (CNA). She presented at your office nine months ago, stating that she needed help with anxiety, which had increased recently due to several stressful life events, including several moves and the start of a new job.
At the time of her intake, Ellen had just moved back into her parents’ home, after a falling out with her roommate of three months. She had also started a new job, working the night shift at a long-term care facility. Ellen told you that though living with her parents was difficult because she often argued with them, she was enjoying her new job. She felt camaraderie with the other night staff, and she found the night shift to be more peaceful than the often-hectic day shifts that she has worked in previous jobs.
Ellen stated that she’d been in therapy previously to work on difficulties related to her trauma history, generalized anxiety and major depressive episodes. Throughout your work with her you began to see evidence of some traits of borderline personality disorder, including emotional lability, problems controlling anger and difficulties in interpersonal relationships. Over the course of several weeks she described a long history of interpersonal conflict with family and peers. In particular, she related that she often felt taken advantage of and resented being asked to do more than she thought was fair. She also told you that she frequently feels misunderstood and talked down to by peers.
Ellen stated that her goals, in addition to better managing emotions, included saving money and eventually getting an apartment of her own. She noted that her parents were supporting her financially and that they had frequently come to her assistance in times of distress. She wished to be more self-sufficient.
Problems at work. Several months into your work together Ellen starts to mention difficulties with some of her co-workers. She states that there are two in particular who seem to have it in for her. She believes that they are gossiping about her and she knows that one of them has complained to a supervisor that Ellen isn’t doing her fair share of the general night duties.
Over subsequent sessions Ellen reports increasing disenchantment with her new job. She reports often feeling tired because she is not able to sleep soundly during the day, and she senses that the interpersonal stressors and lack of sleep are contributing to her anxiety and difficulties regulating emotions. She tells you that she has spoken with her supervisor about this and requested a transfer to the day shift. The supervisor informed her that there were no open positions on the day shift and when such positions opened they would be offered to CNAs with the most seniority. Ellen relates that she is extremely disappointed and mentions repeatedly that they do not understand how difficult this is for her.
Ellen’s Request: At your most recent session, Ellen appears with a letter in hand. She explains to you that it is a request for accommodations, because, as a person with emotional difficulties, she believes that she has a right to work the day shift. The letter is addressed to the director of human resources at the facility, and it outlines the negative effects that working the night shift has been having on her mental health as well as the specific accommodations (i.e., day shift work with a specific schedule) that she desires. At the bottom of the letter, below her signature, is a space for you to sign your name in order to indicate your endorsement of her request.
What to do?
Ellen’s request raises both clinical and ethical considerations, including:
Do you believe that a more regular work and sleep schedule working will positively affect Ellen’s symptoms of anxiety and emotional lability?
Do you believe Ellen’s problems with co-workers would be helped by transfer to a new shift? Given that Ellen has had difficulties with co-workers in the past, might it not be more helpful for her to focus on solving these interpersonal problems?
Do you have concerns about the consequences of Ellen’s challenge to her supervisor’s previous answer regarding a shift change in light of the fact that one of her stated goals is to retain her job in order to earn enough money to live independently?
Is it possible that this request for special treatment is consistent with Ellen’s history of being rescued by her parents from uncomfortable situations? If so, is it therapeutic for you to become part of this system?
Do you worry about your own relationship with Ellen if you do not comply with her request?
Do you believe that you have sufficient basis for recommending the change in shift? Even if you do believe that working the day shift might possibly have a positive impact on her immediate distress level, do you think that it would be in her long term best interests for her to do so?
Would you feel comfortable supporting your client being given preferential treatment for a day shift position over individuals who have worked their way up in the system?
Are there reporting or compliance issues under the Americans with Disabilities Act that pertain to Ellen’s request for accommodations?
The ethical principle most relevant to this situation is Principle 9.01, Bases for Assessments, which states:
“Psychologists base the opinions contained in their recommendations, reports and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings.” (APA, 2010).
Based on the information provided in this vignette, we do not believe that there is clear and sufficient evidence to state that a different work schedule would positively impact Ellen’s symptoms of anxiety and emotional lability. There are also relevant clinical considerations. You might very well suspect that accommodating this request would reenact the familial rescue pattern in a manner that would ultimately not be therapeutic for Ellen. In fact, agreeing to sign this letter might be missing an opportunity to work with Ellen on some problems that are likely to reoccur if they are ignored or avoided in this instance. On the other hand, it is almost certain that your refusal to sign her letter would lead to a challenging interaction. Many psychologists would experience a pull to comply with Ellen’s request in order to avoid conflict. If you are unable to say “no” to an inappropriate request from a client, it may signal that this is a situation in which your professional effectiveness is at risk of being compromised. We would strongly encourage clinical consultation to ensure that you are able to provide effective treatment to Ellen.
In considering your response to this dilemma, it might also be useful to have some familiarity with the Americans with Disability Act and appropriate disability regulations in your jurisdiction. Although a full discussion of the ADA is beyond the scope of this article, readers interested in learning more about how the ADA is applied in cases of psychiatric illness can read the document, “EEOC Enforcement Guidance on the Americans with Disabilities Act and Psychiatric Disabilities” at http://www.eeoc.gov/policy/docs/psych.html. Another excellent resource regarding the ADA can be found at the US Department of Justice’s comprehensive website regarding the ADA (ADA.gov) including instructions for obtaining confidential consultation and filing of complaints.
* Reprinted by permission of the North Carolina Psychologist and the authors. The North Carolina Psychologist, Vol. 65, No.3, May-June 2013.
The Case of Dr. Klein:
A Difficult Referral from a Valued Colleague
The Case of Dr. Klein presents a dilemma that is likely to become more common as psychologists expand their roles in integrated care settings. Questions to consider as you read this vignette include: (1) What is in the patient’s best interest; (2) how can one manage an unintentional dual role on multiple levels; and (3) what steps, if any, could have been taken prior to seeing the patient that might have prevented the dilemma? It is also important to recognize that physician and psychologist ethics tend to differ when it comes to multiple relationships.
Dr. Klein has been employed in an integrated primary care clinic and local hospital for the past five years and has worked as a psychologist in total for nine years. She is well respected amongst her physician colleagues and her practice has grown by word of mouth so that she now receives frequent referrals from physicians outside of the group. She feels confident in consulting with the physicians in her practice and accepts warm handoffs (referrals that are made the same day as the medical appointment) frequently in the clinic. Although she primarily serves in an integrated care capacity (e.g., seeing patients for time limited brief visits at the time of their medical appointments), patients are often scheduled for follow up appointments. As a result, she is now scheduled without an immediate opening for the next three weeks. Dr. Daniels, a physician colleague in the clinic, asks if she is willing to see one of his patients. Even though she is somewhat overextended, Dr. Klein accepts the referral as Dr. Daniels is a valued colleague who refers appropriate patients to her on a regular basis. Dr. Daniels makes the comment that it would be better if the patient could be seen sooner rather than later due to the level of distress the patient’s family is reporting and because it seems like psychosocial stressors are at the root of the concern. Dr. Klein decides to make an exception and overbooks an appointment for this patient for later in the week.
Later that week, Dr. Klein greets Ms. Wade. She is a 19 year old female, who immediately states that her parents have accompanied her to the appointment. She reports that she thinks she has an anger problem. For example, she described recently having an argument with her partner (to whom she is married) when he was driving and acknowledges that she attempted to exit the vehicle while it was traveling at approximately 55 mph. She also described several other incidents in which she has instigated an argument with her partner’s family members because she feels as though they deliberately attempt to make her miserable. For example, at a family function, the family members prepared only food that she disliked and made it impossible to spend time with her partner because of planned activities. When asked why she is seeking help at this time, Ms. Wade stated that her partner has threatened to leave her and she feels as though she cannot live without him. She reported that her partner’s family is upset that they decided to marry so impulsively and are attempting to sabotage the relationship. She further elaborated that she attempted suicide by overdose last week but did not seek help or even let anyone know.
After a thorough diagnostic interview with behavioral observation of labile emotions, Dr. Klein believes that Ms. Wade has some borderline personality disorder features, severe depressive symptoms, and is at high risk for self-harm. Dr. Klein asks if she could invite her parents to attend the appointment to get collateral information. Ms. Wade agrees to this request. As a Certified Nursing Assistant escorts the parents to the room, they are introduced as Mr. and Mrs. Greenwood. They report concerns about their daughter’s very intense moods and concur with each other that they have had significant difficulty with her since she was 16 years of age. This additional information offers further support for Dr. Klein’s diagnostic impressions.
Dr. Klein suggests that the best course of action for Mrs. Wade would be to admit her to an inpatient unit for stabilization and to have her evaluated by the psychologists who specialize in Dialectical Behavior Therapy (DBT). Mr. and Mrs. Greenwood agree that their daughter needs treatment but are concerned about stigma if she were to be admitted. In the process of meeting with the parents, they inform Dr. Klein that Mr. Greenwood is CEO at the hospital where Dr. Klein and Dr. Daniels have privileges, and that Mrs. Greenwood is the teacher of Dr. Daniels’ eight year old son. They request that Dr. Klein attempt to manage their daughter’s symptoms on an outpatient basis with the assistance of Dr. Daniels. When Dr. Klein consults with Dr. Daniels, he suggests that the parents’ request is reasonable and offers to follow the case with her.
What to do?
The patient and family’s request along with Dr. Daniels’ response raises both clinical and ethical considerations, a few of which are detailed below:
Is it possible for Dr. Klein to manage this patient’s care effectively and efficiently via an integrated primary care model?
Does Dr. Klein have the resources and appropriate context to provide the care that the patient needs?
In what ways might Dr. Klein’s relationship with Mr. Greenwood, as the CEO of the hospital where she and Dr. Daniels have privileges, constitute a significant multiple relationship?
How might this multiple relationship impact Dr. Klein’s effectiveness or competence?
How might the relationship that Dr. Daniels has with the patient’s family impact Dr. Klein’s treatment of the patient?
Could the potential negative impact of these multiple relationships be minimized via psychoeducation to all parties?
How might Dr. Klein have a conflict of interests because her reputation and referral base is obtained from the physicians that she works with?
Should there be discretion with some of the clinical findings and recommendations when consulting with Dr. Daniels?
The ethical principles most relevant to this situation are the following:
General Principle A. Beneficence and Nonmaleficence, General Principle C: Integrity, 1.03 Conflict between ethics and organizational demands, 2.01 Boundaries of competence (a), 3.05 Multiple relationships, 3.06 Conflict of interest, 3.09 Cooperation with other professionals, and 4.06 Consultations (APA, 2010).
Based on the information provided in this vignette, there appear to be myriad factors that are likely to negatively impact Dr. Klein’s ability to successfully navigate this particular clinical concern on an outpatient basis. These include coordinating care with a colleague (Dr. Daniels) who may feel intimidated by the patient’s parents, and not having sufficient time (and possibly not specific training) to provide DBT, which is the accepted evidence based treatment for the patient’s likely diagnosis. Therefore, it would almost certainly not be in the patient’s best interest to continue care in a setting that precludes optimal care. In addition, due to the complexity of the multiple relationships, Dr. Klein would most likely not be able to remain objective and minimize the difficulties that would reasonably be expected to arise from the multiple relationships. Furthermore, it would be especially contraindicated to have these multiple relationships given the potential diagnosis of borderline personality disorder. While it is not clear if Dr. Klein has competency in the area of DBT, even if she does, it does not appear that this approach would be feasible with her current practice model. Even though it would be a difficult course of action, Dr. Klein should seriously consider referring the patient to a provider in a system of care that can most effectively provide the care. Dr. Klein may need to engage in a difficult, but necessary conversation with Dr. Daniels regarding her rationale for making this referral. It is possible that a clear message regarding the needs of their daughter would help the patient’s parents to be on board with Dr. Klein’s recommendations. The patient’s recent high risk behaviors (attempting to jump out of a moving car and overdose) and continued suicidal risk could be emphasized to the patient and her parents.
An issue that deserves consideration is the ability of psychologists to co-practice with other professions, whose clinical practice patterns and ethical guidelines may differ with regard to multiple relationships. It is also likely that consultation with another psychologist could prove helpful to Dr. Klein. She has been working in a setting with colleagues who are not psychologists, and may be at risk of losing touch with the ethical and clinical perspectives of her profession. More frequent contact with her psychologist colleagues would likely offer invaluable consultation and professional support for her to remain committed to enacting professional norms related to maintaining best practices in clinical care and the effective management of multiple relationships.
The Case of Dr. Martin:
Compromised Colleague with Multiple Sclerosis
Working closely together day after day can reveal the best – and the worst – in our colleagues. As psychologists, we are generally able to distinguish a minor or time-limited deviation from a typical behavioral pattern of competent professional practice from a more pervasive type of problem. However, the former may evolve into the latter, presenting a professional challenge fraught with difficult decisions when it comes to the sometimes-conflicting goals of protecting patient care and supporting our colleague, who may also be a friend.
Dr. Martin has worked in your clinic for several years and is highly liked and respected for her clinical expertise and pleasant personality. However, over the past several months, you have witnessed – and even been the victim of – uncharacteristic explosive verbal attacks by Dr. Martin. Initially, staff and colleagues tried to overlook these extremely atypical incidents and assumed that Dr. Martin, like any other human being, must be going through a particularly difficult or stressful personal time. Finally, three of the clinic psychologists approached Dr. Martin directly in an attempt to both curtail the inappropriateness of her behavior at work and to also offer support to a colleague and friend who appeared to be in distress. The intervention was not a success. Dr. Martin exploded in a mixture of tears and personal verbal assaults, accusing everyone of conspiring against her because of alleged jealously of her high level professional esteem and success. Even more concerning, these episodes seemed to be increasing in both intensity and frequency with time, to the point that patients began to complain about or leave treatment. Several threatened to complain to the state Board of Psychology, and others appeared both angry at and devastated by Dr. Martin’s behavior.
It also became apparent that Dr. Martin was becoming cognitively impaired. For example, a patient seeking treatment for bereavement issues after the death of her husband left treatment angrily after Dr. Martin attempted to address ongoing marital conflict. Another patient had called and asked the receptionist to assign her to another psychologist because Dr. Martin repeatedly called her by different names from session to session. More than one patient had become tearful following Dr. Martin verbally lashing out, accusing them of not trying hard enough or not being motivated enough to improve. The behaviors that Dr. Martin’s colleagues had tried to overlook or rationalize were now clearly affecting her patient care as well as the professional reputation of the practice as a whole.
At the insistence of her colleagues, Dr. Martin finally agreed to consult with her primary care physician who referred her to a neurologist. Following a comprehensive evaluation, Dr. Martin’s symptoms of memory impairment, confusion, fatigue, sudden mood swings, anger outbursts and personality changes, combined with a history of muscular weakness and dyscoordination, led to a presumptive diagnosis of Multiple Sclerosis (see sidebar for a detailed listing of common symptoms of MS). History revealed waxing and waning symptoms over a several month period. An MRI and spinal tap revealed brain lesions and the presence of monoclonal antibodies in spinal fluid confirmatory of the diagnosis.
What to do?
Dr. Martin is a highly trained psychologist who appears to be unable to provide competent care to her patients, and indeed may be engaging in behavior that directly harms patients. Her colleagues are faced with several ethical dilemmas and challenging questions:
Should steps should be taken to report her as an impaired provider?
If so, what should these be?
What liability do individuals and employers accrue in reporting an impaired provider?
What issues accrue when an impaired provider’s actions fall outside acceptable standards of care, and what is the responsibility of colleagues and employers in such instances?
How can colleagues provide best support to an impaired provider?
Ethical principles involved: General Principle A: Beneficence and Nonmaleficence; Standard 3.12 (Interruption of Psychological Services); Standard 1.05(Reporting Ethical Violations). Other standards or laws involved: Americans with Disabilities Amendments Act of 2008.
Dr. Martin’s colleagues should develop an action plan that effectively balances colleague support and patient protection, carefully weighing the potential positive and negative outcomes associated with each alternative. If Dr. Martin continues to resist the team’s interventions and insists that she could continue to practice, they should contact the Board of Psychology. Since it is their legal charge to regulate the practice of psychology, the Board is in the best position to determine if Dr. Martin was in need of a fitness for practice assessment. A number of state Boards have committees that manage issues pertaining to impaired colleagues, and many state or provincial psychological associations have similar standing committees. Dr. Martin’s colleagues should investigate the presence of such resources at the board or association level and make appropriate inquiries. Even if the team believes that Dr. Martin’s behavior is most likely caused by MS, they should be aware that her behavior could cause harm to clients or create legal risk for the practice. Here, the team should follow the precepts of the ADA, which clearly allows for reporting of impaired behavior that directly affects an individual’s ability to perform occupational functions. Under the Act, employers may request medical or mental health evaluations if they have a reasonable belief, based on objective evidence, that an employee’s performance of essential job functions may be impaired by a medical or mental health condition. Employers, however, must limit their request for evaluation only to the effects of an observed condition on the employee’s ability to carry out essential job functions. Here, of course, we presume that the group practice had the status of an “employer” – i.e., that all professional associates held an employee-employer relationship with the practice. It is important for such practices to examine their articles of incorporation and malpractice insurance status to ensure that actions of impaired associates are addressed.
Sidebar: Diagnosis of MS
No single test can confirm or rule out MS. Neurologists consider medical history along with analysis of spinal fluid, MRI, and evoked potentials (EP) in accordance with the McDonald Criteria when making a diagnostic decision.
Evidence of damage via clinical symptoms or MRI detected lesions in two or more separate areas of the central nervous system (brain, spinal cord, or optic nerves)
Evidence that the damage occurred one or more months apart
3.) Evidence that the damage is not caused by another disease
Emotional Symptoms of MS*
Dramatic mood swings (happy, sad, angry)
Low frustration tolerance
Cognitive Symptoms of MS
Attention and concentration deficits
Slow information processing speed
Difficulty with abstract reasoning and problem solving
Impaired visual spatial abilities
Impaired executive function
*(as abstracted from the National Multiple Sclerosis Society, http://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms)
Prudence F. Cuper, PhD, is psychologist in private practice in Durham, NC. Dr. Cuper completed her graduate training at Duke University and her internship and postdoctoral training at Duke University Medical Center. In 2012. she co-founded the Cognitive Behavioral Therapy Center of the Triangle, where she provides services to adolescent and adult clients. Dr. Cuper has co-authored several articles on ethical dilemmas in psychology. She became a member of the NCPA's Ethics Committee in 2012.
Dr. Wise is Clinical Professor and Director of the Psychology Training Clinic for the Department of Psychology at UNC-Chapel Hill. She is a former chair of the American Psychology Association's Ethics Committee and the North Carolina Psychology Board. Her professional interests include education and training, and applications of ethics and self-care in academic and professional practice settings. She has been credentialed by the National Register since 1992, and currently serves on the National Register Board of Directors.
Since 2007, Dr. Clark has been a member of the psychology faculty at the University of Mississippi Medical Center. Dr. Clark received her PhD in counseling psychology from the University of Southern Mississippi in 2005. She completed her postdoctoral fellowship at University of Mississippi Medical Center in the department of family medicine. Dr. Clark is President of the Mississippi Psychological Association. She has been credentialed by the National Register since 2010, and currently serves on the National Register Board of Directors.
Dr. Shelton received her PsyD in clinical health psychology from Spalding University in 2005. She was appointed Chief Resident at Northeastern Ohio Universities College of Medicine for her internship year. She then competed two postdoctoral fellowships at the Medical College of Georgia; one in medical psychology and the other in behavioral medicine and also earned a Master of Public Health degree before becoming faculty in the Department of Pediatrics and Department of Psychiatry and Health Behavior. Dr. Shelton's primary academic affiliation is with The Chicago School of Professional Psychology. Additionally, she has a private practice, Psychological Wellness Group, in her hometown of Paducah, KY; and is also the chair of the Kentucky Psychological Association Communication Committee. She has been credentialed by the National Register since 2007, and currently serves on the National Register Board of Directors.
American Psychological Association (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://apa.org/ethics/code/index.aspx
Americans with Disabilities Amendments Act of 2008 (P.L. 110-325), 42 USC, sec.12101 et seq.
U.S. Equal Employment Opportunity Commission (1997). EEOC Enforcement Guidance on the Americans with Disabilities Act and Psychiatric Disabilities: Notice Concerning The Americans With Disabilities Act Amendments Act Of 2008 (EEOC Notice Number 915.002). Online access verified 29 September 2014 at http://www.eeoc.gov/policy/docs/psych.html.
Polman, C. H., Reingold, S. C., Banwell, B., Clanet, M., Cohen, J. A., Filippi, M., et al (2011). Diagnostic Criteria for Multiple Sclerosis: 2010 Revisions to the McDonald Criteria. Annals of Neurology, 69, 292–302.
Wise, E. H. (2014). Concerns about colleagues: Re-envisioning our ethical responsibility. The Register Report, Spring, 2014, 28-31.