By Adam Fried, Ph.D. & Melissa Flint, Psy.D.
Being a practicing clinical psychologist is challenging for many reasons. In addition to the nature of the work, which often requires significant concentration and time, there are a multitude of important logistical and practical issues that also require attention. Like many other health care professionals, psychologists must make split-second decisions that can have significant ethical implications. This column differs slightly from previous columns because we wanted to focus on some types of ethical violations that frequently appear before ethics boards that are more practical (and often preventable).
Communicating with Licensing Boards
The are several requirements of licensed psychologists to remain in good standing with their state’s licensing board. Psychologists’ attention is often on the laws and regulations that directly affect our work, such as informed consent and record-keeping but there are smaller (but still critical) tasks, such as license renewal and reporting address changes, that can have significant implications (this can be especially challenging for psychologists who hold licenses in multiple states). For example, boards review cases of psychologists who do not renew their license but continue to practice. Psychologists who do not renew their license face the possibility of violating laws regarding the practice of psychology (namely, practicing without a valid license). In some states, this may require the psychologist to repay monies paid (either to an insurance company or patient/client) for the time the psychologist was not licensed as well as risking disciplinary actions from a board.
Although email has made communication much easier and faster, there are some risks. For example, psychologists have reported that emails from boards about license renewals have been sent to their “spam” folder without the psychologist ever seeing the message. As a result, many recommend not simply waiting to receive the notification from the board that the license is up for renewal but being more proactive by adding notes or alerts to one’s personal calendar when the renewal will be coming. This will also help ensure that psychologists have time to complete any mandatory continuing education (CE) credits (and be sure to document and keep records of these!), as CE requirement deadlines are often tied with license renewals. Although not usually a board issue, being similarly proactive about malpractice insurance renewals to prevent lapses is also critically important.
Many boards require licensed psychologists to report relevant changes in the psychologist’s life or work. For example, psychologists need to inform the board of address changes; failure to report or failure to report in a timely manner may constitute an ethical violation in some states. Some states also require psychologists to report if they have been charged with misdemeanors or other offenses, such as driving while intoxicated.
Finally, communicating and responding to correspondence from the board is a largely preventable issue, but one that happens more than necessary. Ignoring and/or otherwise not responding to board requests for information can lead to more serious complications and questions from the board.
Supervision Planning
Being able to conduct therapy or assessment as a graduate student, intern, postdoctoral fellow or other trainee requires being able to practice under a supervisor’s license. This work is a critical component of the trainee’s education, not only for skill development but also in the socialization in the responsibilities and expectations of professional psychologists. As such, supervisors provide an invaluable service to the field. One of the most difficult areas for supervisors is relying on trainees to relate what is happening. Research (e.g., Mehr, Ladany & Caskie, 2015) suggests that trainees don’t always tell their supervisors what is happening, which can make supervision especially challenging. While psychologists may not have complete control over what is told (or not told) by supervisees, it’s important to have a process for supervision by regularly asking about (and properly documenting) all of the supervisee’s cases and activities [see Falender & Shefranske (2021) and Campbell (2006) for helpful models, tips, and strategies; see also Fried & Powell (2021) for a discussion of ethical supervision in assessment settings].
There are several preventable but important supervision issues that can come before boards. The first is ensuring that the supervision is provided (both in terms of frequency and format) in ways that meet state laws and requirements. Public health emergencies (such as COVID-19) can prompt temporary or even permanent changes (e.g., the use of telesupervision) that psychologists may not be aware of unless they proactively search the laws and regulations of their state. It is also critical that supervisors are aware of when these accommodations might expire, which is different for each state.
Other potential violations that may be preventable with proper planning and forethought pertain to supervisor availability. For example, requirements that trainees are able to access and contact a supervisor are usually outlined in state laws and regulations. Problems and complaints can arise when psychologists go on vacation without making proper arrangements or assume that other colleagues are available to supervise.
Finally, states often have requirements about the titles that can be used by students and trainees in advertisements and communication with clients/patients. When supervising a trainee, it’s important to consult what words are not permissible. For example, using the term “psychologist” even if accompanied by words like “trainee” or “unlicensed” may not be congruent with state laws. Similarly, representing to clients/patients that the trainee has credentials, education or authority that are inaccurate or potentially misleading can also constitute an ethical violation.
“Scope Creep”
This final one issue we wanted to highlight isn’t as practical, but one that can lead to ethical complaints and may be preventable. Our Industrial Organizational Psychology colleagues can likely share many stories of project “scope creep”, where the deliverables change with little notice, more is asked of the consultant, and the focus of the project shifts. This concept has applicability outside of Industrial Organizational work as well. Have you ever considered the concept professional practice scope creep?
In clinical practice, this can occur when additional asks are made of the psychologist that fall outside of their trained scope of competency. A client/patient might say something like “Can you just write me a letter that says ‘X’?” or “Even though you don’t typically see adolescents with a diagnosed eating disorder, I know you’ll be able to help my child”. While a comprehensive investigation of why this tends to occur is outside of the scope of this column, we suggest that a reason might be the desire to attempt to fulfill the needs and wishes of the client/patient. As a result, however, the psychologist can blur boundaries and end up practicing outside of their competence (see also APA Ethics Code (2017) Standard 2.01 Boundaries of Competence).
Another plausible reason why psychologists practice outside of their competency areas might include the belief that they are competent to do anything and everything with every age group just because they were trained as a clinical psychologist. Is it possible to demonstrate competence in all areas of psychology? Put another way, would you be able to demonstrate educational, training, or supervised experiential training in a particular specialty area of psychology if asked by a board? Of course, if you have a desire to add additional areas of treatment or expertise in the future, there are methods available to gain requisite competencies through additional education, training and supervised experience.
One of the dangers of “scope creep” is that it can be insidious. The case that started out with merely counseling a newly single mother coping with post-divorce adjustment can change quickly with a seemingly benign client/patient request to write a letter about custody. Is it ok to write a letter to the court suggesting that your client/patient get more parenting time, given your role, competencies, and the fact that you haven’t interviewed others relevant individuals (including the father)? This is an example of a type of “scope creep” (and potential multiple relationship) case that can come before the board. You might be very effective at doing therapy with someone dealing with the anxieties of their divorce and changing life dynamics but given your role and scope of competence, are not in a position to opine in a custody case (see also APA Ethics Code (2017) Standards 2.04 Bases for Scientific and Professional Judgments, 3.05 Multiple Relationships, and 9.01 Bases for Assessments). As a self-reflective psychologist, it is likely that any request that results in you saying, “just this once”, “how hard could that be?” or “as a favor…” should require additional scrutiny.
Conclusion
While there may be times when a psychologist may not be able to foresee a potential ethical complaint, there are several areas in which proactive planning can help to prevent or mitigate the negative effects of one. In the busyness of our business, it is critical that we give attention to what may seem like little things which can have big, unintended consequences.
References
American Psychological Association (2017). Ethical principles of psychologists and code of conduct (Amended January 1, 2017). Retrieved from https://www.apa.org/ethics/code
Campbell, J. (2006). Essentials of Clinical Supervision. John Wiley & Sons Inc.
Falender, C.A., & Shafranske, E.P. (2021). Clinical Supervision: A Competency-based Approach, Second Edition. Washington, D.C.: American Psychological Association.
Fried, A.L. (2021). “Could You Write a Letter for Me….?”: Ethical Considerations in Patient/Client Requests for Professional Letters. The Clinical Psychologist, 74(3), 13-14.
Fried, A.L., & Powell, J.P. (2021). “I’m Afraid to Ask”: Anticipating and addressing trainee ethical concerns about assessment. The Clinical Psychologist, 74(4), 14-17.
Mehr, K. E., Ladany, N., & Caskie, G. I. L. (2015). Factors influencing trainee willingness to disclose in supervision. Training and Education in Professional Psychology, 9(1), 44–51. https://doi.org/10.1037/tep0000028