CPLEE - Management Issues in Therapy

Capacity 

Comprehension 

Voluntariness

psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analyses, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law

psychologists to “maintain confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium

use “coding or other techniques to avoid the inclusion of personal identifiers” when confidential client information is stored in record systems or databases that are “available to persons whose access has not been consented to by the recipient.”

have a plan for protecting the confidentiality of records in the event of their death, illness, or withdrawal from practice for other reasons. Possible alternatives include (a) having an agreement about the management of the records with a responsible colleague; (b) arranging with a professional association to assist in managing or maintaining the records; or (c) having a professional will that designates an executor or other person who will maintain the records, identifies the location of client records, and provides other crucial information.

a licensed psychologist shall retain a patient’s health service records for a minimum of seven years from the patient’s discharge date. If the patient is a minor, the patient’s health service records shall be retained for a minimum of seven years from the date the patient reaches 18 years of age.

if the licensee ceases operation, it has an obligation “to preserve records for a minimum of seven years following discharge of the patient

All providers set forth in subdivision (a) shall ensure the safety and integrity of all electronic media used to store patient records by employing an offsite backup storage system, an image mechanism that is able to copy signature documents, and a mechanism to ensure that once a record is input, it is unalterable. (c) Original hard copies of patient records may be destroyed once the record has been electronically stored. (d) The printout of the computerized version shall be considered the original for purposes of providing copies to patients, the Division of Licensing and Certification, and for introduction into evidence in administrative or court proceedings. (e) Access to electronically stored patient records shall be made available to the Division of Licensing and Certification staff promptly, upon request. (f) This section does not exempt licensed clinics, health facilities, adult day health care centers, and home health agencies from the requirement of maintaining original copies of patient records that cannot be electronically stored. (g) Any health care provider subject to this section, choosing to utilize an electronic recordkeeping system, shall develop and implement policies and procedures to include safeguards for confidentiality and unauthorized access to electronically stored patient health records, authentication by electronic signature keys, and systems maintenance. (h) Nothing contained in this chapter shall affect the existing regulatory requirements for the access, use, disclosure, confidentiality, retention of record contents, and maintenance of health information in patient records by health care providers. (i) This chapter does not prohibit any provider of health care services from maintaining or retaining patient records electronically.”

HIPAA’s regulations regarding denial of access to records generally preempt California law. Specifically, under HIPAA, a psychologist may deny a client access to their record if the psychologist has determined that access is “reasonably likely to endanger the life or physical safety of the client or another person” and the client is given the right to have the denial reviewed.

In contrast, H&SC Section 123115(b) permits psychologists to deny access when they determine there is a “substantial risk of significant adverse or detrimental consequences to a patient in seeing or receiving a copy of the records.”

in terms of psychotherapy notes, California law preempts HIPAA because HIPAA allows for an absolute non-reviewable denial of access to psychotherapy notes whereas California law does not. In other words, upon request from a client, psychologists may give the client access to the complete psychotherapy notes or a summary of them or may decline to provide the psychotherapy notes if there is a legal reason for doing so

an adult client, a minor client authorized by law to consent to treatment, and a client’s representative are entitled to have access to the client’s records but must present the health care provider with “a written request for those records ... [and pay] reasonable clerical costs incurred in locating and making the records available.” The provision of Section 123110(a) with regard to minor clients is consistent with HIPAA’s privacy rule, and the requirement for a written request is consistent with HIPAA as long as the provider has informed the client that they only accept a written request.

H&SC Section 123110(j) prohibits health care providers “from withholding patient records or summaries of patient records because of an unpaid bill for health care services.” This provision is not consistent with Ethics Code Standard 6.03 (Withholding Records for Nonpayment), which states that “psychologists may not withhold records under their control that are requested and needed for a client’s/patient’s emergency treatment solely because payment has not been received”.

a health care provider must permit a client or client representative to inspect the client’s records during business hours within five working days following receipt of the written request, and Section 123110(b) states that a health care provider must ensure that a copy of the client’s record is transmitted to the client or client representative within 15 days after receipt of a written request for the copy.

Multiple relationships are addressed in Ethics Code Standard 3.05 (Multiple Relationships) which states: “(a) A multiple relationship occurs when a psychologist is in a professional role with a person and at the same time is in another role with the same person, at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.”

when psychologists “are required by law, institutional policy, or extraordinary circumstances to serve in more than one role” in a forensic setting, they must clarify role expectations and issues related to confidentiality. An implication of this standard is that psychologists should accept dual roles in forensic settings only when doing so is unavoidable.

forensic practitioners are encouraged to disclose the potential risk and make reasonable efforts to refer the request to another qualified provider.” When referral is not feasible, the practitioner must consider the risks and benefits for all parties and must “seek to minimize the potential negative effects of this circumstance.”

when a client has unpaid fees, a psychologist should first discuss the matter with the client to attempt to reach an agreement that accommodates the client’s financial situation. If a mutually acceptable agreement cannot be reached, a psychologist may use a collection agency or initiate legal proceedings, but only after notifying the client of the intention to do so and giving the client an opportunity to pay outstanding fees within a specified period of time. Also, when a collection agency is used, a psychologist must give the agency only essential information, such as the client’s name and address and the amount owed. Note that the exception to privilege that exists when there has been a breach of duty in the psychotherapist-patient relationship allows psychologists to disclose necessary information during these proceedings: “There is no privilege under this article as to a communication relevant to an issue of breach, by the psychotherapist or by the patient, of a duty arising out of the psychotherapist-patient relationship”

professional services that are provided without charge. Although the term is not used in the Ethics Code, General Principle B (Fidelity and Responsibility) states that “psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage.” Because pro bono services are addressed in the Ethics Code’s aspirational General Principles rather than in its mandatory Ethical Standards, this means that they are recommended by the Ethics Code but not required.

Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if it is not clinically contraindicated, and the resulting arrangement is not exploitative.” For example, barter should be avoided when it is likely to impair a psychologist’s objectivity or otherwise adversely affect the therapist-client relationship or when it is not possible to determine the extent to which a bartered service or good is equivalent in monetary value to the psychologist’s fee 

There is no specific ethical standard that addresses gifts from clients, but psychologists are expected to rely on the general ethical principles and good clinical judgement when deciding to accept or reject a client gift. Factors that should be considered include the ethical principle of “do no harm”, the monetary value of the gift, the personal nature of the gift, a pattern or a one-time occurrence, cultural factors, and how it may impact the ongoing provider-client relationship.

when psychologists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself.

In other words, paying referral fees is not prohibited but, when they are paid to an individual professional (as opposed to a referral service), they must be based on the actual costs and services provided and not simply on the referral itself

To clarify its position on referral fees, the APA released the following statement: The Ethics Code “does not prohibit an independent contractor from paying a percentage of a fee to a colleague as long as the payment is within a reasonable range of the fair market value of the services provided”

Insurance fraud is both illegal and unethical and committing fraudulent acts (which includes insurance fraud) is identified in B&PC Section 2960(n) as unprofessional conduct and a cause for disciplinary action. 

reports to payors for services or sources of research funding, psychologists take reasonable steps to ensure the accurate reporting of the nature of the service provided or research conducted, the fees, charges, or payments, and where applicable, the identity of the provider, the findings, and the diagnosis.” 

Psychologists should notify a client about the kind and extent of information required by the insurance company during the informed consent process as well as about any limitations to treatment resulting from the company’s requirements. If an insurance company refuses to authorize payment for services that a psychologist believes are necessary, the best first course of action is to file an appeal on the client’s behalf. If the appeal is denied, the clinician should discuss the situation with the client to identify options regarding alternative treatment and payment

psychologists must “make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist’s illness, death, unavailability, relocation, or retirement or by the client’s/patient’s relocation or financial limitations.

requires psychologists to “terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service,” and Standard 10.10(c) states that, “except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.”

Standard 10.10(b) permits psychologists to terminate therapy with a client when the client or a person the client has a relationship with (e.g., family member, friend, employer) poses a threat to the psychologist. In this situation, psychologists are not required to provide advanced notification of termination or pretermination counseling to the client. Moreover, prohibitions against breaching client confidentiality do not apply if the psychologist needs to contact the police or others to obtain protection

requires psychologists to “cooperate with other professionals in order to serve their clients/patients effectively and appropriately.” This includes obtaining consultation

 “When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation.”

the psychologist must “carefully consider the treatment issues and the potential client’s/patient’s welfare.” The appropriate course of action will depend on the circumstances. When a client is seeing another mental health professional for a different problem, it is likely to be acceptable for a psychologist to continue seeing the client in therapy.

For example, if a client is receiving therapy from a psychodynamic therapist for problems in their interpersonal relationships and then contacts a behavioral therapist to help them stop smoking, it would be acceptable for both therapists to continue seeing the client.

However, when the client is seeing another mental health professional for the same problem a psychologist is treating, the best course of action would be for the psychologist to discuss their ethical obligations with the client and determine why the client is seeking the same services from two mental health professionals. If the psychologist determines that there is no benefit for the client in seeing both professionals, the psychologist will want to inform the client that it is inappropriate for them to continue treating the client.

permits licensed psychologists to advertise professional services “authorized to be provided by such license within the psychologist’s field of competence in a manner authorized under Section 651 ... so long as such advertising does not promote the excessive or unnecessary use of such services.”

(a) it shall be unlawful for any person doing business in California and advertising to consumers in California to make any false or misleading advertising claim, including claims that (1) purport to be based on factual, objective, or clinical evidence, (2) compare the product’s effectiveness or safety to that of other brands or products, or that (3) purport to be based on any fact.”

Psychologists do not make false, deceptive, or fraudulent statements concerning (1) their training, experience, or competence; (2) their academic degrees; (3) their credentials; (4) their institutional or association affiliations; (5) their services; (6) the scientific or clinical basis for, or results or degree of success of, their services; (7) their fees; or (8) their publications or research findings.” 

(a) Psychologists who engage others to create or place public statements that promote their professional practice, products, or activities retain professional responsibility for such statements. (b) Psychologists do not compensate employees of press, radio, television, or other communication media in return for publicity in a news item. (c) A paid advertisement relating to psychologists’ activities must be identified or clearly recognizable as such.”

“Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence.” 

For instance, because current supervisees are likely to feel obligated to their supervisors, it is likely to be unacceptable for a supervisor to ask a supervisee for a testimonial to include in an advertisement about the supervisor’s professional services.

“psychologists do not engage, directly or through agents, in uninvited in-person solicitation of business from actual or potential therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence.

However, this prohibition does not preclude (1) attempting to implement appropriate collateral contacts for the purpose of benefiting an already engaged therapy client/patient or (2) providing disaster or community outreach services.”

Following the police to a crime scene and handing out business cards to crime victims is an example of an unacceptable uninvited in-person solicitation of business. In contrast, it would not be an ethical violation for a psychologist to give a business card to someone who asks for it or to send a brochure describing their services to individuals or organizations.

such advice must be based on the psychologist’s professional experience and knowledge, must be provided in a manner consistent with the provisions of the Ethics Code, and must not imply that a professional relationship has been established. Note that this Standard does not apply to services that are provided to a client in the context of an established professional relationship – e.g., it does not apply to a psychologist who provides services to a current client via the Internet or telephone.

prohibits plagiarism and notes that it is unacceptable to take credit for someone else’s work “even if the work or data source is cited occasionally.” Standard 8.12(a) states that psychologists should “take responsibility and credit, including authorship credit, only for work they have actually performed or to which they have substantially contributed,” and Standard 8.12(b) notes that principal authorship and co-authorship reflect the relative contributions of the involved individuals and that minor contributions are acknowledged in an introductory statement or footnote. Finally, Standard 8.12(c) states that, “except under exceptional circumstances, a student is listed as principal author on any multiple authored article that is substantially based on the student’s doctoral dissertation.”

In California, the standard of care for telehealth includes: (a) the practitioner to be licensed in California, (b) fees for services and method of payment for services are clarified, (c) confidentiality is ensured regarding all communications between client and therapist and informs the client immediately of any known data breach, (d) risks and benefits of receiving treatment over the internet are discussed so that the client can make an informed decision, (e), written or verbal informed consent is obtained by the practitioner who has ultimate legal authority over the case prior to delivering services via telehealth, and (f) the licensee is competent to deliver such services via telehealth.

must be obtained verbally or in writing prior to the delivery of services. Consent for services should cover “concerns unique to the receipt of psychological health care services via telehealth, including risks to confidentiality and security, data storage policies and procedures specific to telehealth, the possibility of disruption and/or interruption of service due to technological failure, insurance coverage considerations, and other issues that the licensee can reasonably anticipate regarding the non-comparability between psychological health care services delivered in person and those delivered via telehealth.

As long as the case is appropriate for telehealth, a psychologist licensed in California can provide services to an individual located anywhere in the state of California. Temporary telehealth when the client and/or psychologist are outside of California is permitted, but the psychologist should also defer to the laws in each state or jurisdiction involved (e.g., if the California psychologist is on a business trip to Washington D.C. and the client is on vacation in Colorado, both D.C.’s and Colorado’s laws regarding telehealth and treatment in general should be considered).

Even when it comes to interjurisdictional emergency care, the psychologist must meet the requirements for care set forth by the jurisdiction outside of California as well as in California. If a psychologist or patient has moved permanently out of state, the psychologist is still obligated to practice in accordance with the laws and regulations to which the psychologist and/or client has permanently relocated. The Board of Psychology regulates licensees when the client is in California or initiates services in California, but when it comes to telehealth, the bottom line is that, “The board will investigate any complaint made against a California license regardless of where the services were delivered or received”

Section 2936 requires all psychology licensees and registrants to post a Notice to Consumers in a conspicuous place in their office that contains the information listed in answer 2. The information listed in answers 1, 3, and 4 is ordinarily included in a psychologist’s office policies form.

Answer 3 is most consistent with B&PC Section 2290.5(b), which states that, “prior to the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.”

Answer 3 is most consistent with H&SC Section 123149(c), which states that “original hard copies of patient records may be destroyed once the record has been electronically stored.”

The time allowed for providing a record summary to clients is described in H&SC Section 123130. It states that a health care provider “shall make the summary of the record available to the patient within 10 working days from the date of the patient’s request. However, if more time is needed because the record is of extraordinary length or because the patient was discharged from a licensed health facility within the last 10 days, the health care provider shall notify the patient of this fact and the date that the summary will be completed, but in no case shall more than 30 days elapse between the request by the patient and the delivery of the summary.” Therefore, answer 2 is correct.

Although Standard 3.05 of the Ethics Code prohibits certain types of multiple relationships (i.e., those in which there is a risk of exploitation of the client or a loss of objectivity), its prohibition is not absolute. Of the answers given, answer 4 is most consistent with the provisions of this standard and is the correct response. Because you are the only psychologist in the community, you wouldn’t necessarily refuse to work with the woman in therapy but would want to consider the potential consequences before agreeing to do so.

Answer 1 is consistent with Ethics Code Standard 5.02(b), which prohibits a psychologist from compensating employees of the press for providing publicity in a news item about the psychologist or their work.

The uninvited in-person solicitation of business is addressed in Standard 5.06 of the Ethics Code. It generally prohibits psychologists from engaging in uninvited in-person solicitation of business. However, it also notes that the prohibition does not preclude psychologists from “providing disaster or community outreach services.” Therefore, answer 2 is correct.