A young woman who is in graduate school reached out to me with some questions about ethical and legal aspects in the mental health profession. I liked the questions and decided that I would just share my responses with my readers.
- What does being a legal and ethical mental health professional mean to you?
It is important that I follow federal and state laws and regulations regarding my work. I have multiple licenses in NJ, NY, and PA, and each state is a little bit different. The laws are there to protect the client: their care and confidentiality are of utmost importance.
I think there are a lot of awful programs and bad providers out there. They cut corners, claim an expertise that is not there, over bill, over diagnose, don’t get or engage in supervision, and really seem to put themselves and their programs ahead of the clients.
For me, I have to maintain an ethical and legal standard that not only far surpasses the average citizen, but provides a model for other health care professionals. I was trained to put patients first, document everything, and act like anything I do will be reported in the Star Ledger or New York Times.
- What are some firsthand legal and ethical challenges you encountered in your clinical practice? How did you handle the situation?
I had finished up my first year of graduate school in 2005 and was offered a counseling job at a small private practice. On my third or fourth day there, I learned that the owner and head therapist was employing a number of the clients in a side cleaning business. This was a clear violation of boundaries. I asked her about it and she said that she provided a good job for clients that had a hard time finding work. I brought up the NASW code of ethics and she said that the client’s ability to put food on their table and pay their bills was more important. I quit and reported her to the licensing board.
In 2012, I chaired the NJ Heroin and Opiate Task Force. We held hearings around the state. We wrote a report in 2013 that included recommendations to the Governor and the Legislature. Governor Christie’s office sat on the report for almost a year. Frustrated, I began to criticize the Governor on the radio and in various newspapers. Around that time, a complaint was filed against me with the the State Ethics Commission about how I used my role on the Task Force to advance the interests of Rutgers. Upset about this horrifically vile lie of a charge, I reached out to Gov. McGreevey. He was on the Task Force and had been providing me with political guidance for a couple of years. He told me that “this is great. You’ve done nothing wrong. There is no sex, no money, no contracts. You’ll be exonerated. In the meantime, you are going to learn a great deal about the dirty nature of politics.” It didn’t feel like a great experience. It lasted a year and I was fairly stressed out about it. Ultimately, I was found to have not engaged in any wrong doing. Rutgers was wonderful too – they said that if I had done anything wrong, it was Rutgers fault and not mine. To my great satisfaction, the individual who filed the false complaint against me lost his state job and was barred from future public service.
About five years ago, there was a program that I did some part time work for that had a new clinical supervisor that was not providing weekly supervision to the counselors that worked underneath her. I expressed my concern to the owners on multiple occasions through text, phone calls, and emails. I was told that it would be addressed. It wasn’t. I anonymously reported the situation to the state. A day or two later, a state worker reached out to me to let me know there had been a complaint at an agency I worked at and that they were giving me a courtesy heads up. I was infuriated, and told them that I had made the anonymous complaint. Nothing was done. I filed a second complaint on the state’s website. Someone reached out and eventually, the supervisor started provided weekly supervision to the workers. This whole process took three or four months.
A couple of years later I was asked to provide consultation for an outpatient treatment program in NYC. I learned that all of the front-line counselors had been trained to type that their individual and group counseling sessions used motivational interviewing or cognitive behavioral therapy, even when the counselor had little to no idea about those techniques. I expressed my concern to the administrative supervisor and the owner and was told that they do this to stay in compliance with NY’s OASIS regulations and the insurance companies. I told them that it was unethical and that staff needed to be fully trained on these techniques and then to actually implement them. There were other issues; soon, I reported the company to OASIS and resigned.
I don’t expect most mental health professionals or social workers to act like I do. It would be nice, but it is unrealistic. I left jobs and put myself in situations where the state and corporations (a couple of very rich ones with lots of lawyers) came after me. I’m willing to do the right thing even if it puts me in financial danger – I have found that a vast majority of people are unwilling to do that. A lot of times people will say “I have a mortgage to pay” as the reason why the go along with something bad or “I can’t deal with the drama” as to why they don’t report something. Those are terrible excuses. Other times people will say they have a spouse and kids to provide for. This is a bit more understandable but still ultimately wrong.
- From your perspective (whether or not you work with insurance companies), what are the advantages of insurance panels, what are the struggles? Any legal and ethical implications arise as a result of working with insurance companies?
I dislike the insurance companies. I’ve spoken and written about this for over ten years. Insurance companies make money by (a) not paying claims or (b) paying as low an amount as they can.
From 2005 to 2010, I worked at a non-profit intensive outpatient program in Western NJ. I conducted evaluations there and made treatment placement recommendations. More often than not, when I said a client needed to go to inpatient treatment, their insurance company would come back and say that they would approve intensive outpatient only. But if they failed at that level, then they would consider inpatient. This was upsetting to me. I would argue with them, and I usually told the insurance people that I would have no problem writing a letter on behalf of the client’s family if the client overdosed or died that would be used in court to show the negligence of the insurance company that went against my recommendations. Sometimes it worked. Over the years, I have acquired more licenses, more certifications, another masters, and several titles. Insurance companies fight me less and less on these issues, but it is only because of my rank and that I am profoundly aggressive with them.
I have a lot of disdain for mental health professionals who work for insurance companies. Their job is to go against the treating professional’s recommendation and to lower the cost of treatment (and thus securing more profits for their paymaster). I am sure there are some ethical licensed professionals that work for insurance companies and advocate for clients, but I think they are quite rare. Quite rare. For the last ten years, I have taught at the Rutgers School of Social Work. I tell my students that they can always reach out to me, unless they work for an insurance company where they deny or reduce claims. If they do that, they are dead to me. Unless they took the job in order to become a whistle blower.
I am not on any insurance panels. I don’t want insurance dictating how long or how often I can see someone. I don’t want to get on the phone and talk to some officious bean counter about how the client is progressing and to take marching orders about how they want me to proceed. I am also very much against insurance companies telling me how much they will pay me. I understand that most clinicians need to be on panels in order to get clients and make a living, but they have ceded a great deal of power and authority to those insurance companies.
This has happened throughout the medical profession. Doctors really screwed things up by giving in to the HMOs and insurance companies in the 1980s. But that is a story for another time.
- What does a good case note look like, what should be included or excluded? What advice can you give about effective record keeping in general? Is there information that you may reconsider recording due to legal and ethical reasons?
It depends. I tend to not take notes in the Army or with the NY State Police, as I don’t want command to use the notes against those that I treat. Those are unique jobs and unique situations, and not something that I would advise new professionals to get involved with.
But I think that good notes are really, really important. One should write down the day and time you saw a client, how long the session lasted, what was discussed, what plans were made, and a separate analysis of how the client seemed (grooming, language, facial expression, affect).
Over the years, I have reviewed my notes with clients when they are stuck on something. For example, if someone said they were going to write their mom and letter and then didn’t, I would go back to the notes and say, “Hey, seven weeks ago we talked about this and you agreed to it. Then we discussed it again four weeks ago and you said you would do it. These are your words, not mine.” It can be effective at getting clients to move forward.
If you treat a lot of people, the notes are also helpful to the provider as to the client’s history, situation, and plan.
I’ll leave it at this – if you don’t document it, it didn’t happen.
- What factors contribute to your decision of terminating the provision of therapy? How do you approach this process? What ethical aspects must be considered when introducing the idea of therapy termination to a client?
When I’m treating people, I constantly ask how the sessions are going for them. If they are seeing any benefit. What is hard for them. We discuss how long we might work together. Sometimes it is time limited and other times open ended. We regularly discuss it though. When I was in Poland last year with the Army, it was clear that my sessions with clients would end once our deployment was over (that said, I told soldiers they could reach out to me via phone, email, or online if something came up). We discussed what we worked on and their plan going forward and whether or not they would seek additional counseling from someone nearby when they returned to the States. Those are the topics that a mental health professional must cover when they begin to terminate with a client. At the very least, termination should start being discussed when you are halfway through. I do it from the start of treatment though and continually review it.