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Online Course #6: Peer Consultation: Paying Attention to the Ethical Issues

Peer Consultation: Paying Attention to the Ethical Issues
Mary Alice Fisher, Ph.D.

3 CE Credits – 22 test items – $75


This page contains learning objectives, course outline and complete text for this CE course.  You can read the course online, print the course or save it to your computer. 

At the bottom of the course there is a link that allows you to purchase the test. You will be required to create an account (using your email address) so that you will be able to complete the test immediately, or on your schedule.  You may also begin the test and save it to finish at a later time.

Once you submit the online test, it will be automatically graded. You may take the test up to 3 times in order to pass (80% correct out of 22 questions).  Once you pass, you will be required to complete an evaluation form, after which you will be able to immediately download a certificate of CE credits.


LEARNING OBJECTIVES:

This is a beginning to intermediate course. After completing this course, you should be able to:

  1. List some of the ethical issues that must be considered if participating in peer consultation.
  2. Name two ethical issues that must be clarified if participating in peer group consultation.
  3. Describe some things you should consider before providing ethics consultation to peers.

 

COURSE OUTLINE:

   I. Ethical Standards Relevant to Peer Consultation

  1. Seeking Consultation for Achieving and Maintaining Competence
  2. Seeking Consultation if Impaired (i.e., Consultee-Centered Consultation)
  3. Protecting the Identity of a Consultee’s Clients during Consultation
  4. Providing Consultation to Peers
  5. Obtaining a Consultee’s Informed Consent and Protecting Consultee Confidentiality

   II. Legal Issues Relevant to Peer Consultation

 III. Ethical Issues Related to Individual Peer Consultation

  1. Differentiating Consultation from Supervision or Therapy
    1. Is it consultation or is it supervision?
    2. How are they different?
    3. How are they the same?
    4. Is it consultation or is it therapy?
  2. Asking Important Questions About Consultation
    1. What kind of consultation issue is involved?
    2. What type of consultation is it?
    3. What level of consultation is needed?
  3. Providing Individual Peer Consultation to Others
    1. Monitoring one’s own competence to provide consultation
    2. Avoiding Conflicts of Interest
    3. “Referring out”
  4. Contracting for Individual Consultation
  5. Ethical Decisions About Using Technology for Providing Consultation

   IV. Ethical Questions About Peer Consultation Groups

  1. Is It a “Supervision Group” or a Is It a “Consultation Group”?
  2. Is There an Informed Consent Process for Prospective Members?

(Portions of this course were adapted from

Fisher, M.A. (2013).  The Ethics of Conditional ConfidentialityA Practice Model for Mental Health Professionals. New York, Oxford University Press; and from

Fisher, M.A. (2016). Confidentiality Limits in Psychotherapy: ü   Ethics Checklists for Mental Health Professionals. Washington D.C. American Psychological AssociationISBN 13: 978-1433821899


 

TEXT OF CE COURSE

Peer Consultation: Paying Attention to the Ethical Issues

All of the mental health professions encourage practitioners to seek consultation.  This course considers some of the ethical issues relevant to the topic of peer consultation, including issues related to the ethical importance of obtaining consultation, as well as the ethical importance of providing consultation to peers when qualified to do so.  Ethical issues related to peer group consultation are also covered here.  That form of consultation has become increasingly popular, but it is often erroneously referred to as “group supervision,” and that misnomer can have important ethical implications.

I. Ethical Standards Relevant to Peer Consultation
Ethics Codes for all the mental health professions contain requirements about peer consultation. Here, we will consider some of the Ethical Standards about consultation using five ethical categories:

    1. Seeking Consultation for Achieving and Maintaining Competence
    2. Seeking Consultation if Impaired (i.e., Consultee-Centered Consultation)
    3. Protecting the Identity of a Consultee’s Clients During Consultation
    4. Providing Consultation to Peers
    5. Obtaining a Consultee’s Informed Consent and Protecting Consultee Confidentiality

1. Seeking Consultation for Achieving and Maintaining Competence.
Practitioners of all mental health professions are encouraged to seek consultation in order to achieve, maintain, and monitor their competence to practice their profession. For example, “In the process of making decisions regarding their professional behavior, psychologists. . .  consult with others within the field” and specifically “consult with others concerning ethical problems” (APA Ethics Code, “Introduction and Applicability”). “Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work” (APA Ethics Code Principle B: “Fidelity and Responsibility.”)  Psychologists are expected to “consult with others concerning ethical problems” (APA Ethics Code, “Preamble”) and to use consultation to maintain their competence (APA Ethical Standard 2.01a, b, c, d, “Boundaries of Competence”). “When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties” (APA Ethical Standard 2.06, “Personal Problems and Conflicts”).

Similarly, the NASW Ethics Code begins with a Purpose statement in which Social Workers are described as seeking “appropriate consultation when faced with ethical dilemmas” (NASW Ethics Code, “Purpose”), but a there is also separate NASW Ethical Standard devoted to consultation in general:

(a) Social workers should seek the advice and counsel of colleagues whenever such consultation is in the best interests of clients. (b) Social workers should keep themselves informed about colleagues’ areas of expertise and competencies. Social workers should seek consultation only from colleagues who have demonstrated knowledge, expertise, and competence related to the subject of the consultation. . . (NASW Ethical Standard 2.05, “Consultation”)

Counselors are similarly directed to obtain consultation. “When counselors are faced with ethical dilemmas that are difficult to resolve, they are expected to engage in a carefully considered ethical decision-making process, consulting available resources as needed” (ACA Ethics Code, “Purpose”).

Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience (ACA Ethical Standard C.2.a. “Boundaries of Competence”), and “when they have questions regarding their ethical obligations or professional practice” they “take reasonable steps to consult with other counselors, the ACA Ethics and Professional Standards Department, or related professionals” (ACA Ethics Standard C.2.e, “Consultations on Ethical Obligations”).  “When counselors are faced with an ethical dilemma, they use and document, as appropriate, an ethical decision-making model that may include, but is not limited to, consultation, consideration of relevant ethical standards, principles, and laws; generation of potential courses of action; deliberation of risks and benefits; and selection of an objective decision based on the circumstances and welfare of all involved” (I.1.b. Ethical Decision Making).

Furthermore, Counselors also have Ethical Standards that apply only if practicing in ways that are outside the usual rules and boundaries. Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. . . and should “take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs.” (ACA Ethical Standard A.6.b: “Extending Counseling Boundaries”).  Regarding decisions about making exceptions to confidentiality, “Counselors consult with other professionals when in doubt as to the validity of an exception”  (ACA Ethical Standard B2x, “Exceptions”) and seek consultation or supervision when making decisions about confidentiality in end-of-life cases (ACA Ethical Standard B.2.b, “Confidentiality in End-of-Life Cases”).

Finally, mental health professionals of all professions are required to obtain and maintain “cultural competence.”  Ethics Codes contain reminders that consultation can be an important avenue for meeting that requirement.

The APA Ethics Code requires as follows: Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals,  (APA Ethical Standard 2.01(b), “Boundaries of Competence”)

Similarly, “Social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice. These activities may be in the form of direct practice, community organizing, supervision, consultation, administration, advocacy, social and political action, policy development and implementation, education, and research and evaluation” (NASW Ethics Code “Introduction”).  “Social workers should have a knowledge base of their clients’ cultures and be able to demonstrate competence in the provision of services that 9and deal with them responsibly. For additional guidance social workers should consult the relevant literature on professional ethics and ethical decision making and seek appropriate consultation when faced with ethical dilemmas” (NASW Ethical Standard 1.05b, “Cultural Awareness and Social Diversity”).  Furthermore, “Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability (NASW Ethical Standard 1.05c, “Cultural Awareness and Social Diversity).

For counselors, the ACA Ethics Code contains multiple Ethical Standards related to obtaining cultural competence.  For example, “In collaboration with clients, counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly” (ACA Ethical Standard A.2.c, Developmental and Cultural Sensitivity).  Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy. Counselors respect differing views toward disclosure of information (ACA Ethical Standard B.1.a, “Multicultural/Diversity Considerations”).

2. Seeking Consultation if Impaired: Mental health professionals are encouraged to seek consultation if they are impaired or suspect that their own competence is in question. In a later section about types of consultation, this will be described as “consultee-centered” consultation, in contrast to “case-centered consultation” where one of your clinical clients is the focus.  (See Section III-A.)

“Social workers whose personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties interfere with their professional judgment and performance should immediately seek consultation and take appropriate remedial action by seeking professional help, making adjustments in workload, terminating practice, or taking any other steps necessary to protect clients and others” (NASW Ethical Standard 4.05b, “Impairment”).

“Counselors monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired. They seek assistance for problems that reach the level of professional impairment, and, if necessary, they limit,

suspend, or terminate their professional responsibilities until it is determined that they may safely resume their work (ACA Ethical Standard C.2.g, “Impairment”).

3. Protecting the Identity of a Consultee’s Clients/Patients During Consultation. Mental health professionals are all client/patient unless they have first obtained informed consent for such disclosure.

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 they disclose information only to the extent necessary to achieve the purposes of the consultation” (APA Ethical Standard 4.06, “Consultations”).

Similarly, the NASW Ethics Code specifies that “Social workers should not disclose identifying information when discussing clients with consultants unless the client has consented to disclosure of confidential information or there is a compelling need for such disclosure” (NASW Ethics Code Standard 1.07v, “Privacy & Confidentiality”).  Furthermore, “when consulting with colleagues about clients, social workers should disclose the least amount of information necessary to achieve the purposes of the consultation” (NASW Ethical Standard 2.05c, “Consultation”).

For counselors, “Information shared in a consulting relationship is discussed for professional purposes only. Written and oral reports present only data germane to the purposes of the consultation, and every

effort is made to protect client identity and to avoid undue invasion of privacy” (ACA Ethical Standard B.7.a, “Respect for Privacy”).  “When consulting with colleagues, counselors do not disclose confidential information that reasonably could lead to the identification of a client 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. They disclose information only to the extent necessary to achieve the purposes of the consultation” (ACA Ethical Standard B.7.b., “Case Consultation: Disclosure of Confidential Information”).

4. Providing Consultation to Peers. Mental health professionals often receive requests from their peer colleagues to provide consultation services. Sometimes this is for discussing issues that arise in their own clinical cases (i.e., case-centered consultation), sometimes about practice issues (i.e., administrative or issue-centered consultation), and sometimes about personal issues (i.e., consultee-center consultation). These different types of consultation are discussed below in Section III-B. However, professional ethics codes contain some general principles that would apply.   

“(a) Social workers who provide supervision or consultation (whether in-person or remotely) should have the necessary knowledge and skill to supervise or consult appropriately and should do so only within their areas of knowledge and competence. (b) Social workers who provide supervision or consultation are responsible for setting clear, appropriate, and culturally sensitive boundaries” (NASW Ethical Standard 4.01, “Supervision & Consultation”).

“Counselors assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients (ACA Ethical Standard C.2.g, “Impairment”).

5. Obtaining a Consultee’s Informed Consent and Protecting Consultee Confidentiality

Whenever providing or obtaining peer consultation, it is ethically important to begin with an informed consent discussion to be sure that all parties understand what the rules will be.  It is especially important that the consultant and consultee agree about questions related to the limits of confidentiality.  For example, what if the consultee describes something that the consultant is legally required to report?  What if the consultant decides s/he has a conflict of interest?

For psychologists, the informed consent requirement is very specific:

(a) When psychologists conduct research or provide . . . consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code.  (APA Ethical Standard 3.10, “Informed Consent”)

For counselors, there is a similar ethical requirement:

When providing formal consultation services, counselors have an obligation to review, in writing and verbally, the rights and responsibilities of both counselors and consultees. Counselors use clear and understandable language to inform all parties involved about the purpose of the services to be provided, relevant costs, potential risks and benefits, and the limits of confidentiality (ACA Ethical Standard D.2.b, “Informed Consent in Formal Consultation”).

For Social workers who use technology to provide social work services, there is a responsibility to “obtain informed consent from the individuals using these services during the initial screening or interview and prior to initiating services” (NASW Ethical Standard 1.03(f), “Informed Consent”).

II. Legal Issues Relevant to Peer Consultation

Most of the state licensing board regulations, as well as the state statutes and regulations that apply to all mental health professionals, will apply when conducting consultation.  In other words, all the legal issues relevant to providing other services such as therapy and assessment would likely apply also to consultation relationships.

This means that, as described above in Section I.B, the informed consent conversation with prospective consultees must include discussion of the potential limits of confidentiality that will be legally imposed in their state and setting.  This would include such things as state reporting laws that can require mental health care providers to report child abuse or report provider misconduct if these are described by a consultee.  In order to be prepared to describe these potential disclosures to their consultees, consultants must stay up to date about the relevant laws and regulations. 

III.  Ethical Issues Related to Individual Peer Consultation

Most of the Ethical Standards in the Ethics Codes for mental health professionals might be applicable in some way to peer consultation.  Here, however, we will focus on the five ethical issues below:

  1. Differentiating Consultation from Supervision or Therapy
  2. Asking Important Questions About Consultation
  3. Providing Individual Peer Consultation to Others
  4. Contracting for Individual Consultation
  5. Ethical Decisions About Using Technology for Providing Consultation 

1. Differentiating Consultation from Supervision or Therapy

*Portions of this section were adapted from Fisher, M.A. (2013).  The Ethics of Conditional Confidentiality: A Practice Model for Mental Health Professionals.  NY, Oxford U. Press.

The terms “consultation” and “supervision” are often used interchangeably, but from an ethical or legal perspective their differences are more important than their similarities.

This online CE course is about consultation, but people often refer to a consultation relationship as “supervision.” This misnomer can create confusion not only for the consultant but also for consultees, their clients, and the public.  Erroneously announcing that one is “in supervision” or belongs to a “peer supervision group” can imply a level of oversight that does not actually exist through individual consultation or peer consultation groups.

This confusion has been exacerbated by the fact that sometimes the term “supervision/consultation” is  used as if there were no distinction between the two, or as if the two could be combined into the same relationship, perhaps moving from to supervision to consultation and back again within the same session.  This combined term was coined a long time ago (see, for example, Liddle & Schwartz, 1983), and it was sometimes used within the context of a “supervision-consultation continuum” in which the relationship begins as supervision and gradually becomes a consultation relationship (McDaniel et al., 1988).  Meanwhile, the combined term is still being used in various forms, including “supervision(consultation)” (Bogo & McKnight, 2008) and “supervision/consultation” (Borders, 2012; Fruzzetti, Waltz, & Linehan, 1997; and McWilliams, 2004). The risk is that by using such combined terms the nature and implications of the relationship differences will be unclear, and this can have ethical and legal implications for both parties.

1. Is it consultation or is it supervision? “Supervision” ordinarily refers to relationships in which one party is an accomplished professional who takes responsibility for monitoring and guiding the work of one or more less qualified professionals, whether clinical students, resident trainees, licensure candidates, or other unlicensed professionals. Ordinarily, without that supervision, the supervisee would not be considered legally qualified to provide the services that are being supervised. The supervisor is therefore usually considered to be legally responsible for monitoring the services being provided.

“Consultation,” in contrast to supervision, ordinarily refers to a relationship in which someone seeks assistance from another professional, whether because that professional has expertise about a particular area of practice or is a trusted colleague.  The consultee is licensed or otherwise qualified to practice without the consultant’s involvement and is therefore free to follow or to ignore any recommendations provided by the consultant. The consultant is not usually considered legally responsible for the consultees work.

2. How are they different?

Clearly, based just on these definitions, it is apparent that understanding the differences between consultation and supervision can be very important, both ethically and legally.  Here, we will provide a brief review of the differences.

Supervisors serve as gatekeepers to their profession, and they have a responsibility for the enculturation of their supervisees into the mental health professions.  The supervisor has broad ethical and legal responsibilities for the supervisee’s work and can exercise authority over the supervisees work. For that reason, the supervisee has some specific responsibilities:  For example, supervisees must (a) follow the supervisor’s recommendations about the services they are providing.  They must also (b)  provide all identifiable client information that would allow the supervisor to contact the client in the absence of the supervisee; and this means that supervisees must (c) inform prospective patients that they are in supervision and explain the limitations that relationship will necessarily impose on the client’s confidentiality, since the supervisor will need to receive identifiable client information that would ordinarily remain confidential. “Before providing services, students and supervisees disclose their status as supervisees and explain how this status affects the limits of confidentiality” (ACA Ethical Standard F.5.c, “Professional Disclosure”).  Supervisees should receive guidance about how to explain this to their prospective clients.

In contrast, consultation is a relationship between “legal equals” (Knapp & VandeCreek, 2006, p. 151).

Consultees are generally free to decide what problem they will present and can design a plan that addresses the particular objectives of that relationship. The consultant may make recommendations, but the consultee is not ethically or legally obligated to follow those recommendations. Also, the consultee is not ethically or legally free to provide identifiable client information to the consultant unless the specific client has given informed consent for that disclosure.  This consultee informed-consent responsibility to protect client identity is explicit in each mental health Ethics Code.  It is described above and in Section I,C, but it is an ethical rule that bears repeating: Consultees must not provide identifiable client information unless they have first obtained the client’s consent to disclose.  It would apply whether obtaining individual consultation or attending a peer consultation group.  (For discussion of the differences between a consultation group and a supervision group, see Section IV.A. below.)

In other words, the Ethical Standards described in Section I.C reflect the fact that, in consultation relationships, providing identifiable client information to a consultant constitutes a “voluntary disclosure” on the part of the consultee, which therefore requires obtaining consent from the specific client in advance. In contrast, in supervision relationships the disclosure of client information to the supervisor is a “required disclosure” which a person in supervision must explain in advance to all prospective clients in order to obtain their informed consent to accept that limit of confidentiality in order to receive services from a supervisee.

Many mental health professionals tell all prospective patients that they sometimes obtain consultation and may include that statement in their informed-consent documents and conversations.  (E.g., “I sometimes obtain consultation from a colleague in order to be sure I am providing good care.  I will not share identifiable information about you, and I will provide the name of my consultant if requested.”)  This is good practice, but it is not a substitute for obtaining consent from a specific client before disclosing identifiable information about that client during a consultation.

3. How are they the same? One thing that applies to both roles is the importance of the initial informed consent conversation. Mental health professionals who take on the role of supervisor or consultant have an ethical responsibility to explain to their consultees and supervisees exactly what the limits of confidentiality will be in that relationship (e.g., whether the supervisor or consultant will disclose information if it is legally reportable, such as suspicion of child abuse, provider misconduct, etc.).

In other words, an informed consent process is a very important way to begin both consultation relationships and supervision relationships, and this requirement is explicit in mental health Ethics Codes:

Counselors: “Supervisors make supervisees aware of client rights . . . ,  Supervisees provide clients with professional disclosure information and inform them of how the supervision process influences the limits of confidentiality. Supervisees make clients aware of who will have access to records of the counseling relationship and how these records will be stored.” (ACA Ethical Standard F.1.c, “Informed Consent and Client Rights”)

Psychologists: “When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor.” (APA Ethical Standard 10.01c, “Informed Consent to Therapy”)

Social Workers: “Social workers should discuss with clients and other interested parties the nature of confidentiality and limitations of clients’ right to confidentiality.” (NASW Ethical Standard 1.07e, “Privacy & Confidentiality”)

It is important for both supervisors and consultants to clarify with their consultees and supervisees whether or not the existence of that relationship must be discussed with their own prospective clients in their initial informed consent conversations.

Obtaining informed consent at the outset of supervision or consultation means securing a supervisee’s or consultee’s agreement to participate in light of all relevant factors. The specific information included in a supervision contract or other informed consent document varies according to the setting, context, and purpose of the supervision or consultation; supervisor’s or consultant’s preferences; supervisee’s or consultee’s needs; and other factors. When supervisors and consultants prepare clear informed consent materials and address these issues at the outset, both orally and in writing, all parties benefit. Supervisors and consultants become clear about their commitments. Supervisees and consultees know what will be expected and exactly what they must to do to succeed. Both parties are likely to function more effectively, encounter fewer misunderstandings, and experience more satisfaction in their respective roles. (Thomas, 2010, p. 161.)

In other words, this initial conversation benefits not only the consultee but also the consultant.  Preparing for the informed consent conversation has important benefits, because it requires the consultant to think through important details in advance.

Supervisors and consultants who go through the exercise of preparing clear informed consent materials are forced to think through and articulate what they have to offer and what they are committing to provide . . . In short, an informed consent allows contracting parties to elucidate expectations and identify mutually agreed-on goals, . . . to anticipate likely and unlikely difficulties, and to discuss in advance how such problems might be addressed and/or avoided. The process of discussing these expectations and potential difficulties also sets a precedent of addressing related issues as they arise . . . and establishes a clear professional boundary that will set the tone for the relationship. Ideally, an informed consent will both decrease the likelihood of misunderstandings, impasses, and dissatisfaction for both parties and establish a strategy for efficiently addressing problems when they do occur . . . Finally, taking supervisees and consultees through the process of obtaining their informed consent provides a model for them to use in obtaining the consent of those they serve.  (Thomas, 2010, pp. 144-145; 293.)

As described above, the content of these initial informed consent conversations will vary, because the specifics in counseling relationship are different from those in a supervision relationship.  For example, in a consultation relationship the consultee should give no identifiable information to the consultant unless the consultee’s patient has given explicit informed consent for that disclosure. Therapists’ Ethical Standards reflect this requirement.  The APA Ethics Code requires as follows:  “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” (APA Ethical Standard 4.06). The ACA Ethics Code contains an almost identically worded Standard (See ACA Ethical Standard B.7.b). The NASW Ethics Code requires that “when consulting with colleagues about clients, social workers should disclose the least amount of information necessary to achieve the purposes of the consultation” (NASW Ethical Standard 2.05b).

In contrast, in supervision relationships, the supervisor must be given all necessary contact information about the patient, because supervisors are legally responsible for the work and must be able to contact the patient and/or step into the case in the event a supervisee becomes unavailable.  Therefore, as noted above, in supervisees’ initial informed consent conversations they must notify prospective patients that they will be in supervision and that information about them will be shared with the supervisor instead of remaining confidential.

There are available recommendations about what should be discussed during the initial informed consent conversation.

Several of the issues addressed in obtaining informed consent for treatment or assessment are also applicable to supervision and consultation: Anticipated length of service, limits to privacy, fees and related policies, risks and benefits, and maintenance and storage of records are some examples. . . Consumers must receive enough relevant information about all factors that might reasonably influence their decisions. . . Obtaining informed consent at the outset of supervision or consultation means securing a supervisee’s or consultee’s agreement to participate in light of all relevant factors. The specific information included in a supervision contract or other informed consent document varies according to the setting, context, and purpose of the supervision or consultation; supervisor’s or consultant’s preferences; supervisee’s or consultee’s needs; and other factors. (Thomas, 2010, pp. 142-143; 161)

Section III,C (below), “Contracting For Individual Consultation,” provides additional details about information that consultants might decide to include in a consultation contract.

4. Is it consultation or is it therapy? Consultation about clinical cases often involves discussion of the consultee’s emotional reactions to the clients or their issues. Therapists sometimes need to talk through their own issues, whether those arise from countertransference and/or from personal issues they bring to the case themselves.  Discussion of these emotional issues can be an important part of the consultation, But even though consultation may be “cathartic, and even therapeutic,” it is not therapy (Carey-Sargeant & Carey, 2012, p. 77).

If the consultee’s emotional issues become the focus of the consultation, it may be important to refer the consultee to a therapist in order to have a place to give those issues priority.  [See Section III.C.3 re “Referring Out”]

B. Asking Important Questions About Consultation

1. What kind of consultation issue is involved?

Once a consultee presents the problem to the consultant, it can be important to clarify exactly what kind of issue is involved.  According to Stephen Behnke, former director of the APA Ethics Office, “the first step in responding to a request for consultation is to differentiate what kinds of issues the situation raises.”  Issues can include those that are (1) ethical, (2) legal, (3) clinical, and/or (4) risk-management, so it can be helpful to adopt a “four-bin approach to ethics consultation” (Behnke, 2014a, p. 62).

Does this request involve ethical consultation?  If so, the peer consultant will need to be aware (or willing to become aware) of the Ethical Standards in the consultee’s Ethics Code, as well as ethics articles by ethicists or the recommendations in that profession’s ethics texts.  (See Section V, below.)

Does this request involve legal consultation?  If so, the peer consultant will need to be aware (or willing to become aware) of the state and federal laws and regulations that might apply.  Since relevant legal requirements vary widely from state to state, it can be difficult to provide this type of consultation across state lines. Out-of-state consultees can be referred to the professional association in their own state.  (See Section III.C.3, below.)

Does this request involve clinical consultation?  Many consultations involve questions about clinical decisions that need to be made in a particular clinical case.  The consultant who has expertise in providing ethical and legal consultation may or may not have expertise in the particular clinical problem that is being presented.  For example, if the consultant has no experience in treating eating disorders, then at this stage of the consultation there may need to be a referral to a clinician who specializes in that clinical work.  (See III.C.3, below.)

Does this request involve risk-management consultation?  It is possible that in addition to helping the consultee with the previous three types of consultation, there may be a need for a referral to their malpractice insurer in order to have more official risk-management recommendations.

Most likely, however, the potential consultant will need to answer “yes” to more than one of these questions, because most consultations will involve more than one of these “bins”:

It is rare — although it does happen — that a consultation will raise questions in only one of the four bins. Far more often, two or more bins have questions for a psychologist to consider. A disciplined process of going through each bin, first to differentiate the different kinds of questions the consultation raises and then to integrate the bins with one another, represents a thoughtful and comprehensive four-bin analysis. (Behnke, 2014a, p. 62)

For a successful consultation, the four bins must not only be considered separately, but the four issues must be integrated into a coherent whole.

The process of differentiating the four bins — legal, clinical, ethical and risk management — is a process of integrating the bins to form a coherent response to the dilemma. It is important to emphasize that the process of integration depends on a clear and careful differentiation. When questions are not clearly differentiated from one another, it can be difficult to identify what kinds of questions need to be answered to resolve the dilemma

Differentiation and integration are central to the four-bin approach. A comprehensive analysis will entail examining each bin to determine what questions are in the bin, how questions in a particular bin relate to questions in the other three bins, whether the situation requires that a certain bin receive priority over the other bins, how possible tensions among the bins may be resolved, and where the appropriate expertise can be found to answer questions outside the consultant’s expertise. (Behnke, 2014a, p. 62)

It is therefore important to begin the consultation relationship with an informed-consent discussion that clarifies what kind of consultation the consultee is likely to need, as well as what the consultant is willing and qualified to provide.

Potential consultants must determine whether they feel competent and qualified to offer the particular kind of consultation that is requested.  Since most consultations involve more than one kind of consultation, it can be important as the consultation proceeds that the consultant continue to clarify the kind of consultation that is needed and make decisions about whether it may be necessary to refer the consultee to other resources.  This is an example of why it is important to make informed consent not a one-time thing, but an ongoing process. Consultants must be alert to the possible need to refer the consultee to other resources. (See Section III.C.3, below.)

2. What Type of Consultation is Requested?

Before agreeing to provide peer consultation, it is also important for the potential consult to try to determine which type of consultation is needed.  At the website of our Center for Ethical Practice, we specify that we offer the following four types of consultation:

(a) Case-Centered Consultation

(b) Issue-Centered Consultation

(c) Consultee-Centered Consultation

(d) Practice-Specific or Administrative Consultation

Potential consultants must determine whether they feel qualified to offer the particular type of consultation that is being requested.  As the consultation proceeds, it may become clear that more than one of these types of consultation will be needed, and in that case the consultant may need to make this clear to the consultee.

For example, a case-centered consultation may evolve into an issue-centered consultation; and/or the consultee may feel overwhelmed and needs consultee-centered self-case  consultation; and ultimately, there may be a need to move to administrative consultation to help the consultee develop new policies and informed-consent forms that might help prevent the problem in the future.  Throughout this process, the consultant must continually decide whether s/he is qualified and prepared to offer all of these different types of consultation, and that may or may not require a referral to other consultation resources. (See Section III.C, below.)

Finally, regardless of the kind of consultation, it is important throughout this consultation process that the consultee to provide no identifiable client information.

a) Case-Centered Consultation:

This is probably the type of peer consultation that is most frequently requested. The potential consultee can ask a colleague for help about how to make a decision or how to solve a problem in a specific clinical case.  Consultees sometimes expect a simple “yes or no” answer to their question.   In fact, sometimes there is a very simple answer, but more often the response needs to be more complicated. 

For example, here are some of the consultation questions that might be presented, and although some of them might appear to have “yes or no answers,” none of them are really that simple.

      I see my office mate doing unethical things, but he won’t talk about it.  Should I report him?
The parents of my child patient are demanding the complete therapy record.  Must I provide it?
A pre-adolescent has requested therapy without his parents’ knowledge.  May I see him alone?
      I have received a subpoena for a client’s records.  Is there any way I can protect them? 

Note that all case-centered questions can lead into several different types of consultation.  For example, all of them might have legal implications, so the consultant must be knowledgeable with the state’s laws that will affect the answers. The answer to the first question requires knowledge of the state licensing laws and reporting laws and/or referral to the licensing board.  The second and third questions require knowledge of the state’s laws about parent access to minors’ records and minors’ access to treatment without parental consent.  Answering the last question requires knowledge about the state’s privilege laws.

But also note all case-specific questions can raise “unasked” ethical, clinical, and risk-management questions.  A consultant should raise those issues and help the consultee explore them.  For example, in response to the last question the consultant should make sure the consultee knows not only the available legal options, but also needs to explore the clinical questions (e.g., How is the client responding to this demand for records and how is this affecting the clinical work?  Once informed about the content of the records and the potential implications of making it public, does the client want the record released as evidence in his/her court case?).  Is the consultee aware of the potential ethical and risk-management issues?  Ethics texts and risk-management texts, as well as some Ethics Codes are clear about the fact that disclosing a client record in response to a subpoena alone is not appropriate unless the client has given informed consent to release it (e.g., see APA Practice Organization, 2008;  Koocher & Keith-Spiegel, 2016;  Knapp et al., 2013.)  Therefore, absent the client’s consent, it is ethically inappropriate – and raises risk-management issues – to disclose the record unless a judge orders that it be produced, and that that means taking protective legal measures in order to bring the judge into the picture, such as filing a motion to quash the subpoena. (The specifics will vary from state to state, but see an online example from the state of Virginia at Fisher, 2018.)

Frequently, this type of consultation can be accomplished by telephone or by encrypted email if no patient-identifying information is involved.  But sometimes this type of consultation is best conducted in person or with HIPAA-compliant electronic face-to-face format.

b) Issue-Centered Consultation

This is “preventive” consultation rather than “crisis” consultation. The issue you present may be real or hypothetical, broad or specific. For example, you might request consultation by raising ethical and ethical/legal questions such as:

      What should I do if I ever receive a subpoena for patient records?
What am I ethically required to tell patients at the intake interview?
Must I give patients a written statement about the limits of confidentiality?
Can someone please review my intake forms to see whether they are complete enough?
Do I have options when a law requires me to report something?
What are my ethical obligations if I retire or close my practice?

Sometimes this type of consultation can easily be accomplished by telephone or email.  For example, if the request is to obtain a copy of a specific article, to request the review of an existing document, or to find a link to a particular legal statute, this can easily be accomplished by email, because it includes no identifiable client information

c) Consultee-Centered Consultation

This type of consultation focuses on the consultee’s personal/professional issues, or to consider problems with the personnel issues within the consultees agency, with a goal of understanding whether they are preventing good ethical practice or hindering ethical planning and decision making.

We can help you or your group reflect on your own issues, policies, practices, and ethical dilemmas by asking you to consider personal and professional questions such as:

From an individual practitioner consultee:
      Am I somehow causing this particular ethical issue to arise so often in my practice?
If so, how am I “inviting this trouble” – – and why?
If not, since it predictably recurs, why am I so unprepared to respond when it arises?
Either way, how can I prepare to respond most ethically in the future?
Why am I reluctant to require the billing agent and janitor to sign confidentiality contracts?
Am I ethically and/or legally at risk if they breach the confidentiality of my patients?
Exactly what do I want each contract to require?
From a clinician within an agency:
      Are we somehow causing this particular ethical issue to arise repeatedly in this agency?
Are administrative issues or inappropriate policies obstructing good ethical practices here?
Are all clinical personnel clearly trained about our ethical expectations?
If not, what training is needed?
Do our non-clinical staff breach confidentiality or create other ethical problems?
If so, what training is needed?

 d) Practice-Specific or Administrative Consultation

Sometimes consultation can be helpful to an agency or practice group when devising practice-wide policies, forms, or protocols, or when making administrative decisions about whether to impose uniform ethical procedures.  

For group practices, or in agency settings, we can focus on such possibilities or problems specific to your practice group/agency, or help your group or team problem-solve about policies and decisions specific to your setting.  Examples might include:

      If we change certain policies, what might be the ethical and legal consequences?
Should we standardize our intake conversation about limits of confidentiality?
Should we all follow uniform practices when faced with legal demands for disclosure of information?
Are we dealing ethically with the demands of managed care in our practice?
Are we adequately training our non-clinical staff to uphold ethical standards in this workplace?

Ordinarily, this type of consultation is best conducted in person.  Agency administrators or practice group managers usually prefer to meet at our office in Charlottesville at 934 East Jefferson Street.  The consultation fee is $50/hour or fraction thereof.  If there is a preference for meeting in your own office, there is an additional charge for travel time and mileage.

3. What level of consultation is needed?

Before accepting the opportunity to provide peer consultation to a colleague, it can be important to try to clarify the level of consultation that may be required.  Gottlieb & Handelsman (2013) have proposed a consultation model which involves four levels of consultation.  Their article is about ethics consultation in particular, but these levels would apply to consultation generally, whether the content of the consultation is about ethical issues, or about legal, clinical, risk-management, or personal issues.

These authors suggest that with these four levels in mind, potential consultants can make better decisions about whether to begin a consultation:

Consultations will vary depending on the amount of time, skill, knowledge, and resources the problem will require. This is because dilemmas range from straightforward to highly complex, and as complexity increases the demands on consultants will increase correspondingly. We have found it useful to think of consultations in terms of four levels of complexity ranging from simple factual questions with unambiguous answers to highly complex dilemmas where consultees are highly distressed and exhibit poor self-awareness. We created the categories below as illustrations, but in reality they fall along a continuum of complexity and are not intended as discrete categories with sharp divisions between them. Finally, we assume that during a consultation, the level of complexity may change as new information is obtained. (Gottlieb, Handelsman, & Knapp, 2013, p. 310)

Although there is actually a continuum of complexity in consultations, not four discreet separate levels, but here we briefly describe their suggestions about four levels that can be used as guidelines in decision-making about whether to begin a consultation relationship.

      (a) Level 1: “The least complex and time-consuming consultations are those that contain unambiguous questions that have clear and sufficient answers” (Gottlieb et al., 2013, p. 310).  For example, the prospective consultee might ask for an answer to questions such as “Does my profession have an ethical requirement about reporting …xyz?” or “Does my state licensing board have a regulation about …xyz?” Such questions do have specific simple answers, although the consultant can decide whether to probe further to be clarify whether obtaining this information leads the consultee into other ethical, legal, or clinical complications.

      (b) Level 2: “Sometimes consultees call with questions that appear simple and straightforward to them but which in fact entail greater complexity” (Gottlieb et al., 2013, p. 310).  For example, the prospective consultee might begin with a request for a clinical case consultation raised by a child patient who was anxious about his parents’ separation.  However, in exploring the case details, the consultant might discover that the child was brought for treatment by one of his separated parents who might not actually have the legal authority to obtain mental health services for that child without the other parent’s consent.  Beyond the requested clinical consultation, there may now be a need for a legal consultation.

      (c) Level 3: “Issues at this level may or may not be any more ethically or legally complex than those at Level 2, but they become more difficult and time-consuming when consultees are distressed and/or may not be thinking clearly” (Gottlieb et al., 2013, p. 310).  In such cases, the consultant may need to begin by addressing the consultee’s level of distress and clarifying its potential for preventing clear thinking and effective decision making. “The practical implication of intervention at this level is that it will take far more of the consultant’s time than dilemmas at lower levels because she must first take on a quasi-therapeutic role. . . At this level we assume that this process may take more time but that the goal of helping the consultee gain a better understanding of the situation, and her own role in it, was realistic.” (Gottlieb et al., 2013, p. 311).

       (d) Level 4: “The hallmark of this level is that consultees may not recognize that they need help and/or are resistant to accepting it due to their own distress, conflicts of interest, inadequate socialization into the profession, and/or lack of understanding of their fiduciary obligations.”  The consultant must decide if s/he has the expertise and time to manage what could become a highly complicated and emotional situation that could become “rather time-consuming and perhaps quite demanding of personal resources” (Gottlieb et al., 2013, p. 311).

C. Providing Peer Consultation to Others:

The role of consultant provides a clinician with the opportunity to be a mentor by displaying professional behavior that the consultee will hopefully emulate.  For example, by doing such things as beginning the relationship with an appropriate informed consent conversation as described above, the consultant will be engaging in practices that the consultee should be using in his/her future clinical relationships.

Being in the role of consultant also gives a mental health professional the opportunity to assess a peer’s competence as part of the process of helping to create and maintain a “competent community” of mental health professionals:

Many psychologists never avail themselves of personal psychotherapy . . . or ongoing consultation . . .  Self-assessment of competence is fraught with several disadvantages including the inherent fallibility of human self-assessment and the fact that competence is context driven and vulnerable to decrements in the context of distress (Johnson et al., 2012, p. 559)

It can also be an opportunity to model the ethical decision-making process that is required in some professional Ethics Codes: For example, “For additional guidance social workers should consult the relevant literature on professional ethics and ethical decision making and seek appropriate consultation when faced with ethical dilemmas” (NASW Ethics Code, “Purpose“).  Similarly, “When counselors are faced with an ethical dilemma, they use and document, as appropriate, an ethical decision-making model that may include, but is not limited to, consultation, consideration of relevant ethical standards, principles, and laws; generation of potential courses of action; deliberation of risks and benefits; and selection of an objective decision based on the circumstances and welfare of all involved” (ACA Ethical Standard I.1.b. “Ethical Decision Making”).

During a consultation, the consultant can use one of the many available structured models of decision-making, making that available to the consultee for future use.  Many such models have been developed within a specific mental health profession (e.g., Mattison, 2000; and Raines & Dibble, 2010).  However,  almost all these decision-making models are appropriate for mental health professionals of any discipline.  See, for example, the ethical decision-making model provided by Fisher (2005), which integrates the models from several different professions.

Availability of such multidisciplinary resources can be important in some settings.  For example, McDaniel et al (2002) make a strong case for the fact that professional psychologists in primary care settings are in a position to provide helpful mental health consultation to physicians, nurses, and other medical personnel who might otherwise not have access to mental health consultation. Multidisciplinary consultation can also be important in other settings such as schools, agencies, and multidisciplinary group practice settings.

Additionally, it can also be important for the consultant to be sensitive to – and to model sensitivity to – cultural issues, as ethically required: For example, “In collaboration with clients, counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly” (ACA Ethical Standard A.2.c, Developmental and Cultural Sensitivity).  Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy. Counselors respect differing views toward disclosure of information (ACA Ethical Standard B.1.a, “Multicultural/Diversity Considerations”). Similarly, regarding cultural competence, the ACA Ethics Code contains multiple Ethical Standards related to obtaining the necessary cultural competence.  For example, “In collaboration with clients, counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly” (ACA Ethical Standard A.2.c, Developmental and Cultural Sensitivity).  Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy. Counselors respect differing views toward disclosure of information (ACA Ethical Standard B.1.a, “Multicultural/Diversity Considerations”).

As noted above (see Section III.B.3), one of the roles of a consultant can be the acculturation of others into the mental health profession (Gottlieb et cl., 2013). However, as described in the previous Section (III.B.3), some of the most difficult, taxing, and time-consuming consultations can include those involving colleagues who have been inadequately socialized into the profession.  That makes it important for the prospective consultant to weigh the pros and cons of accepting a consultation case that might involve making up for the education and professional acculturation that should have happened during earlier pre-licensure training and supervision.  At worst case, it may mean that the potential consultee is not suited to be a mental health professional and/or that the consultant will need to report misconduct.

The role of consultant is a professionally important one.  “Calls for consultation are made out of respect; being asked to consult is flattering, and it is always a compliment. Although these requests can be graciously acknowledged, they should not necessarily be granted. For example, it is ill advised to allow oneself to be seduced into offering hasty opinions in areas with which one is unfamiliar. Instead, it is helpful to consider the circumstances and nature of the request before agreeing to consult” (Gottlieb et al., 2006, p. 153).

In other words, the potential consultant should consider carefully before accepting a consultation relationship.  The questions below were among those recommended for use when deciding whether to begin an ethics consultation, but they seem applicable to any kind of consultation relationship.  The authors of the list suggest that “If the answer to one or more of these questions is in the negative, the consultant is well advised to consider referring the consultee to other resources for assistance” (Gottlieb et al., 2006, p. 153):

  1. Am I qualified?
  2. Can I be objective with my colleague?
  3. Do I have the time?
  4. Do I have the needed resources?
  5. Have I considered the legal nature of the consulting relationship?
  6. Am I willing to accept the responsibility for my consultation?

A negative answer to any of the previous questions may prompt the consultant to refuse the consultee’s request. If it is necessary to decline, the prudent consultant may consider explaining his or her reason for doing so—for example, that proceeding with the consultation could harm the consultant–consultee relationship and/or have adverse affects on the consultee, his or her client, and/or others involved. Sensitively refusing in this way acknowledges respect and concern for the welfare of everyone who may be affected.

In addition to the ethical considerations discussed in the sections above, clinicians who decide to provide consultations to peers should keep some other issues in mind.  Here, we will consider the following potential ethical issues

  1. Monitoring One’s Competence to Provide Consultation to Peers: At the very least, someone offering formal consultation should be aware of the relevant Ethics Codes and laws, as well as familiar with the professional literature. It may also be important for a potential consultant to understand the competencies required for performing clinical consultation

Psychologists perform many professional responsibilities during the course of their training and careers. Increasingly, psychologists are called on to provide consultation both in traditional mental health practice and in diverse and ever-expanding professional and interprofessional settings. Although consultation draws on clinical expertise, it is a distinct professional practice that requires clear understanding of its aims and functions as well as the application of a unique set of skills. (Falender & Shafranke, 2020, p. 11)

  1. Avoiding Conflicts of Interest: As a potential peer consultant, it is important to be alert to the possibility that you might have a conflict of interest in a case that will be presented by the consultee. For example, the potential consultant might have a conflict of interest created by a pre-existing role or relationship. This could include having prior knowledge of (or a prior or current relationship with) the client whom the consultee begins to present, or with that client’s family. In such a case, not only might the consultant’s objectivity be impaired, but the consultation might even place the other person at risk. Additionally, having prior knowledge of the client being discussed in the consultation could create an ethical problem, because identifiable information should be brought into the consultation only if the consultee’s client has given consent for that information to be shared.

Several Ethical Standards might apply. “Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation” (APA Ethical Standard 3.06, “Conflict of Interest”).

Similarly, “(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible. In some cases, protecting clients’ interests may require termination of the professional relationship with proper referral of the client . . . (d) Social workers who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a social worker is asked to testify in a child custody dispute or divorce proceedings involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest (NASW Ethical Standard 1.06, “Conflicts of Interest”).

Such a conflict of interest would need to be addressed during the initial informed consent conversation, along with consideration of whether the consultee might need to be referred to a different consultant.  (See Section III.C.3 below.)

3. “Referring out” – It can be very helpful if the consultant is aware of the names of available consultants and therapists who have varying specialties, in the event that a consultee will need to be referred for services for which the consultant will not be available. For example, as described in Sections above, a consultant needs to be preferred to “refer out” a consultee (or potential consultee) if the consultant has a conflict of interest, or if the consultation requires a specialty that is not in this consultant’s repertoire. Such referrals do not necessarily mean that the current consultation relationship must be ended; the two relationships may exist simultaneously.  For example, sometimes a consultant makes a referral to a therapist for dealing with a consultee’s personal or emotional issues, or for providing additional support; but the consultant may decide to continue the case consultation they had already begun.

Similarly, some consultations require extensive ethics consultation, in which case it might be important to refer a consultant who does this type of consultation as a specialty.  Resources are available for those who wish to provide ethics consultation.  (See Gottlieb, 2006; Gottlieb, Handelsman, & Knapp, 2013.)

D. Contracting for Individual Consultation

What information should be covered in an initial informed-consent contract for individual consultation? Peer consultations sometimes occur “on the fly,” when colleagues grab colleagues between sessions to consult about crisis situations.  But at other times, there are planned peer consultation meetings, and at such “formal consultation” times it can be advisable for both parties to be clear about the rules and conditions.

Psychologist Janet Thomas, who has written extensively about consultation and supervision, stresses the importance of the initial informed consent conversation and lists some of the content that it should include, as well as things a formal consultation contract might include:

“Several of the issues addressed in obtaining informed consent for treatment or assessment are also applicable to supervision and consultation: Anticipated length of service, limits to privacy, fees and related policies, risks and benefits, and maintenance and storage of records are some examples. . . Consumers must receive enough relevant information about all factors that might reasonably influence their decisions. (Thomas, 2010, p. 142-143)

Thomas recommends that consultation contracts delineate what the consultant agrees to do. Rather than take responsibility for a therapist’s entire caseload, a consultant might agree to field particular questions or cases that the consultee chooses to raise. Or the consultant might offer an educational consultation focused on the use of a particular type of assessment instrument, learning to apply a particular theoretical orientation, or improving boundaries with clients. Such a contract need not then specify which issues the consultee must inform the consultant about.  Rather, the consultee chooses which issues he or she wishes to raise. And, unlike supervisors, consultants are not ultimately responsible for decisions. Therefore, the contract should include a clear statement, signed by the consultee, emphasizing that the consultee is ultimately responsible, such as the following: “The consultant will offer suggestions and ideas. I may choose to accept and implement, modify, or ignore these suggestions. I understand that responsibility for clinical decisions regarding my clients rest solely with me.” (Thomas, 2010, p. 160-161; emphasis added)

Interestingly, the professional literature seems to contain few recent references to consultation contracts, and no examples of sample contracts.  A recent brief literature search turned up numerous references to consultation contracts in articles published in the 1980s, but almost no recent references.  Thomas (2010) has provided a form for “summarizing” a consultation or supervision case, but she provides no sample contracts.

Appendix 1 of this course therefore provides a sample consultation contract.  It is really a “skeleton” contract that suggests some things that might be included and agreed-upon between consultant and supervisee.  It will need to be edited and expanded to meet the specific conditions in each consultant’s own policies.  For example, many important issues may need to be added to this contract, including the question of whether or not the consultant will maintain records of the consultation.

E. Using technology to request or provide consultation (e.g., email, blogs, listservs, etc.)

National mental health associations are recognizing both the benefits of technology and its ethical risks.  The latest Ethics Code of the American Counseling Association (APA) (2014) included an entire new section related to use of technology in providing services, as well as references to technology in other sections.  The National Association of Social Workers (NASW), instead of providing a separate section, has included references to technology throughout the 2017 revision of its Ethics Code.

National mental health associations have also recently provided extensive separate documents about the use of technology for providing clinical services. For example, the American Psychological Association has provided Guidelines for the Practice of Technology (2013) and has also published A Telepsychology Casebook based on that document (Campbell, Millán & Martin, 2018).  Similarly, the National Association of Social Workers has joined with other groups to provide Standards for Technology in Social Work Practice (2017). In addition, many state licensing boards are providing guidelines.  (For example, see Virginia Board of Psychology, 2018 and Virginia Board of Social Work).  Additionally, multiple articles and books are emerging on this topic.

Consultants should become and remain familiar with their profession’s documents related to the use of technology in providing services.  Most of the recommendations contained in such documents would apply not only to those who provide therapy and assessment, but also to those providing consultation.

If consultation will be provided at a distance, rather than face-to-face, a consultant needs to be sure to  use HIPAA-compliant software or encrypted email.

Finally, social media technology is becoming increasingly popular, and in some ways it can be very helpful to mental health clinicians, including consultants.  It can be ethically safe to use it for some purposes: “Listservs can be enormously helpful in seeking referrals, and in identifying professionals with specific expertise in a given area or literature relevant to a clinical question. Listservs can also be very useful in identifying important clinical considerations for a given condition or disorder and in calling attention to unique complexities and important competencies in certain treatments” (Behnke, 2007, p. 62).  However, when participation in a listserv is used by mental health professionals as a format for obtaining online consultation from listserv members about a specific client, or for venting about particular clients or types of clients, it raises big issues about potential client identifiability, breaches of confidentiality, and other ethical breaches: “When postings on listservs move the focus from more general issues to discussing details of a specific individual’s clinical situation, the ethical issues become significantly more complex. Our ethical scrutiny of how we use the Internet therefore rises correspondingly” (Behnke, 2007, p. 62).

IV. Asking Ethical Questions About Peer Consultation Groups.

 A. Is it a “Supervision Group” or is it a “Consultation Group”?

This question points to an ethically-important distinction.  “Peer group consultation at times is incorrectly referred to as peer supervision despite the absence in the group of any person with the authority inherent in the supervisory role” (Bogo & McKnight, (2008), p. 52).

Group supervision is the regular meeting of a group of supervisees (a) with a designated supervisor or supervisors, (b) to monitor the quality of their work, and (c) to further their understanding of themselves as clinicians, of the clients with whom they work, and of service delivery in general. These supervisees are aided in achieving these goals by their supervisor(s) and by their feedback from and interactions with each other. (Bernard and Goodyear, 2004, p. 244)

Conversely, consultation groups may or may not have a designated leader, and the format is generally more flexible and variable. A consultation group consists of peers who share common professional goals or interests. Each individual retains complete legal and clinical responsibility for his or her own work. (Thomas, 2010, p. 164)

Peer consultation groups can take many different forms.  They can be deliberately “homogenous,” as when all members are specialists in a particular treatment modality (e.g., eating disorders, EMDR) or in working from a particular theoretical orientation (e.g., psychoanalytic, behavioral, etc.).  Sometimes, however, there can be advantages to belonging to a more “heterogenous” group, because it allows participants to learn from each other about possible ways to respond to a wider range of clinical issues.

Peer consultation groups also vary in how they are structured and whether there are designated leaders.  For example, some peer consultation groups are “consultant-initiated” and/or “consultant-led,” in which case the group may have a specifically-designated leader; but this does not mean the initiator or leader is a “supervisor” or that this circumstance automatically creates a “supervision group.”  As explained by Thomas, one person with particular expertise might create and market the group, and establish a fee for members of the group, but this does not mean the consultant is accepting legal responsibility for the work of members.  “The consultant leads the group and determines its focus, format, schedule, and ground rules and screens and selects members. The consultant may offer information and recommendations but does not have the responsibility or authority to require particular actions or to determine which cases are presented” (Thomas, 2010, p. 166).

Other peer consultation groups might be designated as “invited consultant groups,” with one person with particular expertise is designated as an unpaid group leader. Again, although this person may take the lead in establishing such things as “focus, format, schedule, and ground rules” and may “screen and select potential members and may offer information and recommendation” s/he may not have “the responsibility or authority to require particular actions or to determine which cases are presented” and  has no ethical or legal responsibilities about members’ clinical work (Thomas, 2010, p. 166)..

Ordinarily, however, peer consultation groups consist of “colleagues with similar levels of professional experience . . . For example, clinicians in independent practice “may decide to assemble a group of colleagues to discuss their cases. Depending on their needs and objectives, they may choose to collaborate with colleagues located in the same office or building, or they may seek out colleagues who share a theoretical orientation or who engage in a particular type of work.”  Finally, mental health professionals employed in agencies or clinics often have access to consultation groups in their work settings. Sometimes attendance in such groups is mandatory. However, they may decide to supplement this mandatory consultation with membership in an outside peer consultation group (Thomas, 2010, p. 166).

B. Is There an Informed Consent Process for Prospective Members?

* Portions of this section were adapted from: Thomas, Janet T. (2010). The Ethics of Supervision and Consultation: Practical Guidance for Mental Health Professionals.  Washington, DC, US: American Psychological Association. (Chapter 6, “Informed Consent to Supervision and Consultation, pp. 141-161.

In preparing for organizing and maintaining a peer consultation group, it would be important to decide what the policies will be and what rules will be enforced.  To ensure that potential members understand those in advance, they can be included in an informed-consent contract.

˃ Have We Explained the Confidentiality Rules to All Group Members?

˃ Have We Clarified When Recusal Might Be Ethically Necessary?

˃ Do We Monitor Competence and Compliance with the Established Ethical Rules?

˃ Will We Be Expected to Report If a Peer is Engaging in Unethical Practices?

It has been suggested that rules such as these might be included in such an initial contract:

  1. Rule: Agree to protect the confidentiality of all information shared by participants in consultation group, both patient information and personal information.
  2. Exceptions to the rule: Legally required disclosures, including reports of abuse, etc.
  3. Take care not to use identifying information about the patients whose cases are being discussed unless their consent has been obtained in advance.
  4. Take responsibility to recues yourself if a presented patient is known to you and is therefore identifiable.
  5. Agree to appropriately dispose of any written case information shared by other group members.
  6. Help ensure that meeting locations will allow protection of privacy and confidentiality, and agree not to carry the confidential discussion out into hallways or public places.

BIBLIOGRAPHY

American Association of Marriage and Family Therapy (AAMFT). (2015).  Code of Ethics.         Alexandria VA: Author.  Retrieved from http://www.aamft.org/imis15/Content/Legal_Ethics/Code_of_Ethics.aspx [1]

American Counseling Association (ACA). (2014). ACA Code of Ethics and Standards of Practice. Alexandria, VA: Author. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=4 [2]

American Psychological Association (2013). Guidelines for the Practice of Telepsychology.  American Psychologist 68 (9), 791-800

American Psychological Association (APA). (2017). Ethical Principles of Psychologists and Code of Conduct (2002, Amended June 1, 2010 and January 1, 2017). Retrieved from http://www.apa.org/ethics/code/index.aspx [3]

Bailey, Deborah S.  (2003, October).  Ethics as prevention.  Monitor on Psychology, 34 (9), 68.  Retrieved from http://www.apa.org/monitor/oct03/ethics.aspx

Behnke, S.  (2007, July-August). Ethics and the internet:  Requesting clinical consultations over listservs. Monitor on Psychology, 38 (7), 62. Retrieved from    http://www.apa.org/monitor/julaug07/ethics.aspx

Behnke, S.  (2014a, February).  What kind of issue is it?  Monitor on Psychology, 45 (2), 62.  Retrieved from http://www.apa.org/monitor/2014/02/issue.aspx

Behnke, S.  (2014b, June). Talking about ethics.  Monitor on Psychoogy, 45 (6), 64. Retrieved from http://www.apa.org/monitor/2014/06/ethics.aspx [4]

Bernard, J.M. & Goodyear, R.K. (2004).  Fundamentals of Clinical Supervision. Needham Heights, MA, Allyn & Bacon.

Campbell, L.F., Millán, F. & Martin, J.N. (2018).  A Telepsychology Casebook. Washington, D.C. American Psychological Association.

Carey-Sargeant, C.B. & Carey, L.B. (2012). Peer-Group Consultation.  Journal of Clinical Practice in Speech-Language Pathology, 14 (2).

Center for Ethical Practice (undated).”Consultation.”  Retrieved from https://centerforethicalpractice.org/consultation/ [5]

Falender, C. A., & Shafranske, E. P. (2020). Consultation in psychology: A distinct professional practice. In C. A. Falender & E. P. Shafranske (Eds.), Consultation in psychology: A competency-based approach (p. 11–35). American Psychological Association. https://doi.org/10.1037/0000153-002 [6]

Fisher, M.A. (2013).  The Ethics of Conditional ConfidentialityA Practice Model for Mental Health Professionals. New York, Oxford University Press

Fisher, M.A. (2016). Confidentiality Limits in Psychotherapy: ü   Ethics Checklists for Mental Health Professionals. Washington D.C., American Psychological AssociationISBN 13: 978-1433821899

Fisher, M.A. (2018). Ethical and Legal Responsibilities of Virginia Mental Health Professionals in Response to a Subpoena.  Retrieved from https://centerforethicalpractice.org/respondingtoVirginiasubpoenas [7]

Fruzzetti, A. E., Waltz, J. A., & Linehan, M. M. (1997). Supervision in dialectical behavior therapy. In C. E. Watkins, Jr. (Ed.), Handbook of psychotherapy supervision (p. 84–100). John Wiley & Sons Inc.

Gottlieb, M.C. (2006).  A template for peer ethics consultation.  Ethics & Behavior, 16 (2), 151-162.

Gottlieb, M.C., Handelsman, M.M.. & Knapp, S. (2013). A model for integrated ethics consultation.  Professional Psychology: Research and Practice, 44 (5), 307-313. DOI: 10.1037/a0033541

Johnson, W. Brad, Barnett, Jeffrey E., Elman, Nancy S., Forrest, Linda & Kaslow, Nadine J. (2012). The competent community:  Toward a vital reformulation of professional ethics.  American Psychologist, 67 (7), 557-569. DOI: 10.1037/a0027206

Knapp, S.J. & VandeCreek, L.D. (2006).  Practical ethics for psychologists: A positive approach. Washington, DC: American Psychological Association.

Knapp, S. J., VandeCreek, L. D., & Fingerhut, R. (2017). Practical ethics for psychologists: A positive approach. Washington, DC: American Psychological Association.

Knapp, S., Younggren, J.N., VandeCreek, L., Harris, E., & Martin, J. (2013). Assessing and managing Risk in Psychological Practice: An Individualized Approach. The Trust, Rockville, MD.

Koocher, G.P., & Keith-Spiegel, P. (2016). Ethics in psychology and the mental health professions: Standards and cases. (3rd Edition). New York: Oxford University Press.

Liddle, H.A. & Schwartz, R.C. (1983).  Live supervision/consultation: Conceptual and Pragmatic Guidelines for Family Therapy Trainers. Family Process, 22, 477-490.

Mattison, M. (2000) Ethical Decision Making:  The Person in the Process.  Social Work, 45, 201-212.

McDaniel, S.H., Campbell, T., Wynne, L.D. & Weber, T. F. (1988).  Family systems consultation: Opportunities for teaching family medicine. Family Systems Medicine 6 (4), 392-403.  https://doi.org/10.1037/h0089758 [8]

McDaniel, S.H., Belar, C.D., Schroeder, C., Hargrove, D.S. & Freeman, E.L. (2002).  A Training Curriculum for Professional Psychologists in Primary Care. Professional Psychology: Research and Practice, 33 (1), 65-72.

McWilliams, N. (2004). Some observations about supervision/consultation groups. New Jersey Psychologist.  apadivisions.org. Retrieved from https://www.apadivisions.org/division-31/publications/articles/new-jersey/mcwilliams.pdf [9]

National Association of Social Workers (NASW) (2017).  Code of Ethics. Washington DC: Author.

NASW, ASWB, CSWE, & CSWA (2017).  Standards for Technology in Social Work Practice.
Online at http://bit.ly/2sFmTwI [10]  (64 pages)

Orlowski, J.P., Hein, S., Christensen, J.A., Meinke, R. & Sincich, T. (2005).  Why doctors use or do not use ethics consultation.  J. Med Ethics,  32, 499-502.  doi: 10.1136/jme.2005.014464

Raines, J. & Dibble, N. (2010) Ethical Decision Making in School Mental Health.  New York: Oxford University Press

Thomas, Janet T. (2010). The Ethics of Supervision and Consultation: Practical Guidance for Mental Health Professionals.  Washington, DC, US: American Psychological Association

Virginia Board of Psychology (2018).  Guidance on Electronic Communication and Telepsychology.  Retrieved from https://www.dhp.virginia.gov/Psychology/psychology_guidelines.htm [11]

Virginia Board of Social Work (2018). Guidance Document 140-3: Guidance on Technology-Assisted Therapy and the Use of Social Media. https://www.dhp.virginia.gov/social/social_guidelines.htm [12]


Websites with Related Ethical Resources

Center for Ethical Practice – http://www.centerforethicalpractice.org/consultation/
(see “Ethical and Legal Resources”)

Pope, Kenneth S. – See Ethics section at kspope.com


 

APPENDIX 1:

 

CONSULTANT’S LETTERHEAD

Informed Consent for Clinical Consultation
(Consultant-Consultee Contract)

I wish to receive consultation services from Mary Alice Fisher, Ph.D., Clinical Psychologist.  I understand that these consultations do not constitute clinical supervision and that I remain completely responsible – ethically and legally – for the decisions I make. Dr. Fisher will provide me with an opportunity to discuss clinical cases and issues about which s/he may have some expertise, and she may offer suggestions and ideas, but the comments she makes for my consideration are not supervisory mandates.  I understand that the responsibility for my decisions will rest entirely with me.

I understand that we will begin with my brief description of the question or dilemma that brings me to the consultation. Dr. Fisher may then help me identify the relevant ethical, legal, clinical, and/or risk-management issues involved, but her emphasis will be on helping me clarify the ethical issues involved.  She may refer me to other consultants if she perceives a need for more emphasis on legal and/or risk-management issues.  She is not offering ongoing, long-term clinical case consultation or supervision. If she perceives that this is needed in my case, she will refer me to a clinical consultant.

I understand that I may sometimes need to discuss personal issues that may be relevant to my clinical work and that we may need to identify and explore any of my emotional responses that are affecting my work or creating ethical or clinical issues in the situation I am presenting to Dr. Fisher.  However, I also understand that her consultation services do not constitute psychotherapy.

I understand that ordinarily Dr. Fisher will maintain the confidentiality of this consultation relationship to the extent legally possible, but that there are potential limits to the confidentiality she can offer. I understand that if I provide any information about which my consultant has an ethical or legal obligation to disclose information or to make a report, s/he will inform me at the time and will give me the opportunity to make the report myself.

I also understand that to the extent possible, I am expected to protect the confidentiality of my own patients/clients as I participate in this consultation relationship.  My case presentations will provide no identifiable information about any clinical patients/clients unless I have obtained their informed consent for such disclosure.

I understand that if Dr. Fisher becomes aware that s/he knows or has a prior relationship with the presented client(s), or if she believes she has a potential conflict of interest in her relationship with me, she will notify me of that fact immediately and will cooperate in helping me find a different consultant.

I agree to the fee of $100.00 per one-hour consultation session, pay or $50 for a consultation that last a half-hour or fraction thereof, payable after each meeting.

_____________________________    ___________________________________  _____________
(Name of Consultee — please print)              (Signature of Consultee)                              (Date)

 

*NOTE: This is a sample form, designed for training purposes. For use in your own setting, this form must be personalized to reflect your actual policies.

(© 2020), Mary Alice Fisher, Ph.D.


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