Ethics

WHO ARE MENTAL HEALTH PRACTITIONERS?

Mental health practitioners are highly skilled licensed professionals who are trained to provide assessment and therapy for individuals, groups and families. The licensing and certifying boards and colleges for the various service providers have as their first mandate the task of protecting the public by ensuring that all practitioners with a license or certification offers services of the highest quality. They are also there to accept complaints by clients and to act on these complaints. The licensed or certified professionals include clinical social workers, psychologists mental health nurses, family doctors, psychiatrists, occupational therapists, guidance counselors among others. When consulting a practitioner, it is important to ask about their license or certification. The consumer must know that if a practitioner is not licensed or certified by a provincially mandated body, the client has no protection in the event of malpractice nor do they have any guarantee of the practitioner’s competence.

WHO ARE PSYCHOLOGISTS

Psychologists are professionals that are specifically trained at the masters and doctoral level in the area of talk therapies, evaluation and life planning. During this training they learn how to help individuals increase their awareness and management of their problematic behaviors, thoughts and emotions. They are also trained in how to best implement individual and group level interventions and how to evaluate therapeutic progress.  Their tasks include acting as diagnosticians, treatment planners and providers, evaluators in custody cases and determiners in questions such as readiness to return to work, academic abilities, emotional health and parental competence. These are heavy responsibilities and as a result, psychologists are governed by one of the strictest codes of ethics in mental health professional practice. Like medical doctors, psychologists undergo a long and rigorous period of supervised practice after their university studies are completed. New aspiring psychologists will work closely with an experienced licensed psychologist for up to three years during which every aspect of psychological practice will be reviewed and perfected. During this time, these graduates will refer to themselves as “Residents in Psychology” and their clients will also be clients of the supervising psychologist.

You may also encounter clinical psychology students who, as part of their studies, will accompany a licensed clinician. These students do not have their own clients but may sit in on work being done by licensed psychologists to begin the long process of learning the skills needed to be an independent clinician. These are often referred to as practicum students or as interns.

WHEN DO YOU CONSULT A MENTAL HEALTH CLINICIAN

Many adults or children experience personal problems at different times in their lives. Usually they are able to work them out by themselves or with the help of family and friends. When attempts at working things out do not bring relief, seeking help may be of considerable benefit. This is especially true when the problems begin to interfere with the normal daily activities and in important relationships. Problems that individuals frequently consult mental health clinicians for would include anxiety, problematic or uncontrolled emotions such as fear, anger or depression, social difficulties such as extreme shyness or fear of public places, family problems, eating problems, uncontrolled stress, marital problems, school related difficulties, and problems at work. Some individuals will have more severe and long lasting mental illnesses such as schizophrenia or important and persistent mood disorders. Still others will consult mental health clinicians because they are not sure just what is wrong in their lives and they need help defining the problem more clearly before tackling it, a process called diagnosis.

HOW DO MENTAL HEALTH CLINICIANS WORK FOR THEIR CLIENTS

A clinician will usually begins by developing a working relationship with you in much the same way other professionals would, that is, by being as specific as possible about what needs to be done and what are the best ways of doing it. Usually the following
steps are taken:
1. The clinician will first inform you about the ethics of clinical relationships including issues like confidentiality and its limits, billing practices, approaches most often used and the clinician’s responsibility to stay within their areas of competence.
2. Next, the clinician will help you to define just what your work together will be. This may involve some assessment procedures to help define the problem better.
3. Once the problem is defined, the clinician will describe to you the service approach she/he feels will best answer your needs. He/she will also try and give you an idea of how many visits or sessions will be needed.
4. In describing the services offered, clinicians are obliged to describe other approaches which could be used in treating the problem. Should you choose a treatment option that is not available through the clinician, then he/she must make reasonable efforts to redirect you to a professional who is able to offer the other service if possible.
5. It is also true that some clinicians will devote much of their work to treating a certain type of problems. If a clinician feels that you would be best served by one with greater experience in treating your particular problem, he or she will make this clear to you.
6. At times, the therapy approach recommended will include medications. There are a number of conditions where medications are very important. Psychologists do not prescribe. Psychiatrists or other medical doctors are the only ones that can prescribe these medications. Other clinicians may inform you of the advisability of considering the use of medication but only a psychiatrist or other medical doctor can actually prescribe it for you.

WHAT IS CONFIDENTIALITY

Confidentiality is a word used to indicate that your identity and the information you give to a clinician cannot be given or shared with anyone else without your permission. Clinicians are obliged to protect the privacy of their clients in this way. But there are five circumstances where confidentiality can and must be broken. That is if:
1.  the clinician has reason to believe that the client could be a serious danger to
his/herself and that the risk of harm is imminent (may happen within hours or a
few days),
2. the clinician has reason to believe that the client may seriously harm another
person and that the risk of that harm is imminent,
3.when a client informs the clinician that a former licensed medical or mental health clinician has behaved sexually towards a client,
4. when the courts order the clinician to release information to the court and
5. when the clinician learns that any person who is under 19 may be the victim of physical or sexual abuse by another or may suffer from neglect.

In each of these five situations the clinician must act to protect the client, other persons or comply with the court even if consent is not given.

If you are seeing a clinician in a clinic or a private practice where more than one clinician works, it is possible that your clinician will want to consult with other professionals in that clinic or office. In our practice, such consultations do take place on a regular basis. Those who hear the information usually do not hear the name of the persons being discussed. Furthermore, all meeting participants will be licensed clinicians who are equally bound by the obligation to confidentiality. Nonetheless, the clinician cannot discuss your case without having you consent to him or her doing so, a consent that you can withdraw at any time. If you have concerns about this, you should share them with your clinician. If a child or adolescent is being seen individually, the clinician will keep discussions confidential from the parents unless the child or adolescent gives his or her permission. This is often necessary to ensure that important issues are dealt with honestly by the child or adolescent. The parent should remember that the clinician will break confidentiality if he or she discovers that the child or adolescent’s wellbeing is
threatened.

Finally, clients often wonder how they should respond when they see their clinician in a shopping area, in a theater or on the street. Our recommendation is that you not show that you know your clinician. The clinician will likely not acknowledge you or only give you the faintest sign of “hello”. The clinician who does not acknowledge you is not being impolite. Rather, they are avoiding placing you in the position of having to explain how come you know a psychologist, a question that can be awkward.

WHAT IS CONSENT

Consent is a permission you give to a professional who is offering his/her services. Usually, clients are asked to give 2 kinds of consent. These are (1) consent to treatment and to using a specific therapy approach to deal with the problem presented, and (2) consent for releasing information to others. Consents can be verbal or in writing. Issues of consent are usually discussed during the first meeting and most clinicians will have a written consent form available to review prior to commencing therapy. If a child or adolescent under the age of 16 is involved in therapy, the parent will be asked to give his or her consent in the child’s stead. If the client is an adolescent (aged twelve or older), the adolescent and their parent or guardian will both be asked to provide consent for the interventions proposed.

WHAT IS THE CLIENT CLINICIAN RELATIONSHIP

Clinicians are trained to help people deal with difficult and important life situations. For this, clients are asked to reveal more about themselves than they usually would with others. Because clinicians are privy to sensitive information about clients, the professional Colleges and Boards ask all clinicians to abide by a strict code of conduct. This code includes the following:
1. That they will respect the integrity of the client and his family at all times.
2. That therapy issues will not be discussed outside of formal therapy sessions. As we noted above, should you meet in a shopping center for example, one should not ask about the problems that were discussed in therapy.
3. That various forms of personal intimacy (emotional, physical, sexual, close friendship) are strictly prohibited and not allowed under any circumstances between client and therapist.
4. As a rule, touching is not part of the therapist client relationship except for occasional hand shakes with adults or high fives and pats on the head or shoulder (for children). Any other form of touching that might be included in therapy for children (usually related to play) would be discussed in detail with you prior to the therapy and would usually only occur in the presence of the parent.

It is inevitable in smaller communities that clinicians will meet up with some clients in social settings from time to time as already noted. This is especially difficult for the clinician since he/she is the one who is most obliged to respect the rules of confidentiality. For this reason, clinicians usually will say as little as possible if anything to the client in these situations. The client must remember that this is done out of respect for their right to privacy and is not a snub or sigh of disrespect.

RECEIVING AND PAYING FOR PSYCHOLOGICAL SERVICES

Mental health services are free to the public if they are provided in hospitals or in mental health clinics. Mental health clinics are found in every region of New Brunswick and can be accessed directly or through your family doctor. You should call your local clinic for information on how to access their services or speak to your family doctor if you want to access these community resources. There are clinicians who work in other services such as school districts and local Children’s Aid Societies. Each of these agencies will have their own policies regarding how to access clinical services from them. Most psychiatrists services are covered by medicare. Clinicians in private practice are not covered by government medical plans. These other professionals such as psychologists, social workers and nurses must charge for their services as would a lawyer or accountant. Billable work includes therapy sessions, report writing, attending meetings in schools or at work and writing letters. Usually these clinicians will ask for payment at the end of each session. Fortunately, most employee insurance plans and private health insurances cover some or all of the fees these professionals charge. It is useful for the client to check with their insurer to see what their plan covers, which kinds of professionals are included in the coverage and what the limit is for each person in the family might be. For people without insurance and with low incomes, many private practitioners have a sliding fee scales so that the less a person makes per year before taxes; the less they are charged. The number of spaces clinicians are able to dedicate to sliding scale clients tends to be limited and wait times before being seem may be longer for that reason. Clients should check with their clinician for details concerning the fee scales used in their practice and what the wait time might be to access these spaces.

SUCCESS AND FAILURE IN THERAPY

Clients come to the clinicians with the goal of having their problems solved. By and large, most clients are helped through the process of psychotherapy. At times, however, the client’s goals for therapy are not achieved. There are no guarantees of success in the relatively new field of psychotherapy. If the client's needs have not been met within a reasonable time, they should feel quite free to discuss it with the clinician. At that time, the approach may be changed or he/she may refer you to another therapist. Clinicians are taught early that they cannot help all clients and are comfortable with referring on if progress is not sufficient. As a consumer of mental health services, you should not let a therapy that is not working go on forever. You are in charge of the process.

WHO IS THE BOSS

In therapy, the client is always the boss. The clinician is always the employee. As such, the client has the full right to say what they want to work on, what they do not want to work on and when they want the therapy to end. They can assess the success or failure of therapy and can even let the therapist how they think they are doing. The therapist, on the other hand, has to respect the job description that the client gives them. That does not mean that they need to be passive. On the contrary, clinicians are often very forthright and do not hesitate to inform clients about what they see and what they feel needs doing. But the final decision on what gets worked on belongs to the client.

WHAT IF YOU ARE CONCERNED WITH HOW A CLINICIAN HAS PROVIDED SERVICES FOR YOU
If you believe that a licensed clinician has broken the guidelines referred to above, you should discuss it with him or her right away. If your attempts to do so fail or if you feel unable to do so, consulting the College Association or Board that governs his or her profession is an option given to you for your protection. The Boards, Associations and Colleges can be reached by calling the following numbers. Below are the hyperlinks to the various colleges for the principal professions offering mental health services in New Brunswick.

New Brunswick Association of Social Workers
College of Physicians and Surgeons of New Brunswick
College of Psychololgists of New Brunswick
Nurses Association of New Brunswick